Dojčenie a hnačky

Výsledky početných štúdii sa zhodujú v tom, že výživa materským mliekom dojčatá účinne chráni pred hnačkami vyvolanými baktériami ako aj vírusmi. Častosť, závažnosť priebehu a úmrtnosť na hnačky je u dojčených detí podstatne nižšia ako u ich rovesníkov kŕmených umelými mliekami. Svetová zdravotnícka organizácia predpokladá, že v krajinách tzv. tretieho sveta umrie každoročne 1.5 milióna detí na následky umelej výživy (t.j. v prvom rade na hnačky s následnou dehydratáciou a rozvratom vnútorného prostredia). Ochranný efekt dojčenia je však zrejmý aj v rozvinutých krajinách s dobrým hygienickým štandardom. Bez ohľadu na socio-ekonomické postavenie rodiny je riziko hnačkových ochorení u dojčených detí podstatne menšie. Ochranný účinok materského mlieka sa uplatňuje nielen pri výlučnom ale aj čiastočnom dojčení (t.j. u detí, ktoré sú zčasti dojčené a zčasti dokrmované umelým mliekom). V takomto prípade je efekt dojčenia priamo úmerný podielu materského mlieka vo výžive. Privčasné zavádzanie príkrmov (pred 6 mesiacom veku) je takisto spojené s častejším výskytom hnačiek. Najmä u detí žijúcich v zlých hygienických podmienkach sa odporúča dojčenie aj po prvom roku života.

Pediatrics, Vol. 99 No. 6 June 1997, p. e5
A Longitudinal Analysis of Infant Morbidity and the Extent of Breastfeeding in the United States

Paula D. Scariati^*, Laurence M. Grummer-Strawn, and Sara Beck Fein

Background:  Studies on the health benefits of breastfeeding in developed countries have shown conflicting results. These studies often fail to account for confounding, reverse causality, and dose-response effects. We addressed these issues in analyzing longitudinal data to determine if breastfeeding protects US infants from developing diarrhea and ear infections.  Methods: Mothers participating in a mail panel provided information on their infants at ages 2, 3, 4, 5, 6, and 7 months. Infants were classified as exclusively breastfed; high, middle, or low mixed breast- and formula-fed; or exclusively formula-fed. Diarrhea and ear infection diagnoses were based on mothers' reports. Infant age and gender; other liquid and solid intake; maternal education, occupation, and smoking; household size; family income; and day care use were adjusted for in the full models. Results:  The risk of developing either diarrhea or ear infection increased as the amount of breast milk an infant received decreased. In the full models, the risk for diarrhea remained significant only in infants who received no breast milk compared with those who received only breast milk (odds ratio = 1.8); the risk for ear infection remained significant in the low mixed feeding group (odds ratio = 1.6) and among infants receiving no breast milk compared with those who received only breast milk (odds ratio = 1.7). Conclusions:  Breastfeeding protects US infants against the development of diarrhea and ear infection. Breastfeeding does not have to be exclusive to confer this benefit. In fact, protection is afforded in a dose-response manner. The more breast milk an infant receives in the first 6 months of life, the less likely that he or she will develop diarrhea or ear infection. longitudinal analysis, diarrhea, ear infection, breastfeeding.

Breast-feeding and infant illness: a dose-response relationship? 
Raisler J, Alexander C, O'Campo P 
Nurse-Midwifery Program, University of Michigan School of Nursing, Ann Arbor 48109-0482, USA. jraisler@umich.edu
OBJECTIVES: The purpose of this study was to determine whether breast-feeding has a dose-related protective effect against illness and whether it confers special health benefits to poor infants. METHODS: The association between breast-feeding dose and illnesses in the first 6 months of life was analyzed with generalized estimating equations regression for 7092 infants from the National Maternal and Infant Health Survey. Breast-feeding dose (ratio of breast-feedings to other feedings) was categorized as full, most, equal, less, or no breast-feeding. RESULTS: Compared with no breast-feeding, full breast-feeding infants had lower odds ratios of diarrhea, cough or wheeze, and vomiting and lower mean ratios of illness months and sick baby medical visits. Most breast-feeding infants had lower odds ratios of diarrhea and cough or wheeze, and equal breast-feeding infants had lower odds ratios of cough or wheeze. Full, most, and equal breast-feeding infants without siblings had lower odds ratios of ear infections and certain other illnesses, but those with siblings did not. Less breast-feeding infants had no reduced odds ratios of illness. Findings did not vary by income. CONCLUSIONS: Full breast-feeding was associated with the lowest

illness rates. Minimal (less) breast-feeding was not protective. Breast-feeding conferred similar health benefits in all economic groups.

Inequality in infant morbidity: causes and consequences in England in the 1990s. ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood. 
Baker D, Taylor H, Henderson J 
Department of Child Health, University of Bristol.
STUDY OBJECTIVE: To examine the effect of deprivation, crowding, maternal smoking, and breast feeding on morbidity from wheeze and diarrhoea in the first six months after birth. DESIGN: A geographically located population survey using maternal responses on self completion questionnaires. SETTING: The three health districts of Bristol. SUBJECTS: 8501 infants from the Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC) in which all women expecting a baby between April 1991 and December 1992 in Bristol were invited to participate. MAIN OUTCOME MEASURES: The prevalence and severity of wheeze at six months after birth. The prevalence of diarrhoea and the duration of the worst bout at six months after birth. RESULTS: Logistic regression analyses using a conceptual hierarchical framework showed that wheeze was significantly more likely to be reported for infants if they lived in rented accommodation (OR = 1.20, 95% CI = 1.04, 1.39), if they lived in crowded housing conditions (OR = 1.26, 95% CI = 1.06, 1.49), if they were one of a number of siblings (OR = 1.78, 95% CI = 1.52, 2.07), and if their mothers smoked (OR = 1.38, 95% CI = 1.21, 1.58). They were significantly less likely to have wheeze if they were breast fed (OR = 0.68, 95% CI = 0.59, 0.79). Each of these factors was independently related to the prevalence of wheeze. For infants with wheeze those who were breast fed for three or more months were significantly less likely to have three or more episodes in the first six months after birth (OR = 0.76, 95% CI = 0.58, 0.99). A higher prevalence of diarrhoea in infancy was associated with living in rented accommodation (OR = 1.25, 95% CI = 1.10, 1.41) and lower maternal education (OR = 0.76, 95% CI = 0.69, 0.84) and a lower prevalence with breast feeding (OR = 0.42, 95% CI = 0.37, 0.48). An episode of diarrhoea was significantly less likely to last for six or more days if an infant lived in mortgaged accommodation (OR = 1.34 95% CI = 1.03, 1.75) and was breast fed for three or more months (OR = 1.34 95% CI = 1.03, 1.75). CONCLUSION: Deprivation was associated with heightened morbidity from common conditions such as wheeze and diarrhoea for this geographical cohort of infants in England in the 1990s. Results supported evidence suggesting that breast feeding is protective against such conditions and is particularly associated with reduced severity and duration. Implications for future research and policy are discussed.

Gastroenteritis, diarrhoea and breast feeding. 
Golding J, Emmett PM, Rogers IS 
Unit of Paediatric and Perinatal Epidemiology, University of Bristol, UK.
In this paper we review the literature in regard to possible relationships between breast feeding and diarrhoea or gastroenteritis. We show that in the developed as well as the developing world, there is consistent evidence of a protective effect of exclusive breast feeding in the first 4-6 months of life. The odds ratios were generally in excess of 3.0 for non-breast milk feeds. The relationship was not consistent for rotavirus infections but was consistently strong for non-viral pathogens. There are a number of indicators that suggest biological plausibility, in both the developing and developed world. The triple indicators of consistency and strength of the epidemiological associations, together with biological plausibility are major arguments for believing that there is a causal sequence involved.

The associations between feeding modes and diarrhoea among urban children in a newly developed country. 
al-Ali FM, Hossain MM, Pugh RN 
Department of Community Medicine, Faculty of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates.
The protective effect of breastfeeding against infantile diarrhoea may be less pronounced in areas with modern water supply and sanitation facilities. This finding raises the question whether protection by breastfeeding against infantile diarrhoea in developing countries will decline with improvement in water supply and sanitation. To address this question a historical cohort study of the associations between feeding modes and diarrhoea incidence and severity in children aged 0-14 months at baseline was done in Al Ain city, United Arab Emirates. In this city in a newly developed country, modern water supply and sanitation facilities have become available to everyone during the last two decades. During three months of follow-up of 249 children, the nonbreastfed had more diarrhoea than did the partly breastfed, who in turn had more diarrhoea than did the fully breastfed. After multivariate adjustment, this dose-response effect was consistent for three measures of diarrhoeal morbidity in each child: occurrence or non-occurrence of incidence episodes, number of episodes, and total severity score. However, significant differences were seen only between the nonbreastfed and fully breastfed subgroups. These results indicate that in Al Ain, despite the universal access to modern water supply and sanitation facilities, breastfeeding plays an important role in reducing the incidence and severity of infantile diarrhoea. This observation is particularly important given the growing concern that, as an unwanted effect of 'modernisation', breastfeeding is on the decline in Al Ain and comparable populations elsewhere.

Epidemiology of rotavirus diarrhea in Egyptian children and implications for disease control. 
Naficy AB, Abu-Elyazeed R, Holmes JL, Rao MR, Savarino SJ, Kim Y, Wierzba TF, Peruski L, Lee YJ, Gentsch JR, Glass RI, Clemens JD 
Epidemiology Branch, National Institute of Child Health and Human Development, Bethesda, MD 20852, USA.
Reliable epidemiologic data are essential for formulating effective policy to control rotavirus disease through immunization. The objective of this study was to describe the epidemiology of rotavirus diarrhea in a population-based cohort of children under 3 years of age residing in Abu Homos, Egypt, in 1995-1996. Rotavirus diarrhea incidence rates (episodes per person-year) were 0.13 for infants aged <6 months, 0.61 for those aged 6-11 months, 0.17 for those aged 12-23 months, and 0.15 for those aged 24-35 months. Fifty-six percent of children with rotavirus diarrhea had clinical dehydration; 90% of rotavirus diarrheal episodes occurred between July and November. In infants under 1 year of age, receipt of breast milk was associated with a lower incidence of rotavirus diarrhea. No other sociodemographic or environmental factor was found to be significantly associated with rotavirus diarrhea. Of 46 rotavirus isolates with strains identified, 41 (89%) were G serotypes 1 and 2. Rotavirus diarrhea was a major cause of morbidity in this cohort. Promotion of breastfeeding may exert a protective effect in young infants in this setting, but improvements in water and sanitation are unlikely to be effective preventive measures. The use of effective immunization against rotavirus in early infancy should be considered a public health priority.

Role of human-milk lactadherin in protection against symptomatic rotavirus infection. 
Newburg DS, Peterson JA, Ruiz-Palacios GM, Matson DO, Morrow AL, Shults J, Guerrero ML, Chaturvedi P, Newburg SO, Scallan CD, Taylor MR, Ceriani RL, Pickering LK 
Shriver Center for Mental Retardation, Waltham, MA 02254, USA. dnewburg@shriver.org
BACKGROUND: Human milk contains a 46 kDa mucin-associated glycoprotein, lactadherin, which binds specifically to rotavirus and inhibits its replication. This study tested the hypothesis that lactadherin protects against symptoms of rotavirus infection. METHODS: 200 infants in Mexico City were recruited at birth and monitored by regular stool EIA for rotavirus, serology, and recording of feeding and stool patterns. Milk samples were obtained from the mothers weekly until 4 weeks post partum then monthly. The sample taken immediately before an infant's episode of rotavirus infection was assayed for lactadherin, butyrophilin, mucin, and secretory IgA. An infection was defined as symptomatic if diarrhoea occurred in the 5 days before or after detection of the virus. FINDINGS: 31 infants developed rotavirus infection; 15 were symptomatic and 16 had no symptoms. The median concentration of lactadherin in the milk samples (obtained 4-41 days [median 13] before the infection) was 48.4 (range 5.6-180) microg/mL in the asymptomatic group and 29-2 (6.2-103-4) microg/mL in the symptomatic group. Although these medians did not differ significantly, in logistic regression analysis adjusted for age at infection and secretory IgA concentration there was a significant difference between the groups (p=0O01). No association between symptom status and concentrations of butyrophilin, mucin, or secretory IgA was found. INTERPRETATION: Protection against rotavirus by human milk is associated with the glycoprotein lactadherin. This association is independent of products of the secretory immune system.

The impact of infant feeding patterns on infection and diarrheal disease due to enterotoxigenic Escherichia coli. 
Long K, Vasquez-Garibay E, Mathewson J, de la Cabada J, DuPont H 
Departamento de Nutricion y Salud del Nino, Instituto Nacional de Salud Publica, Cuernavaca, Morelos, Mexico.
OBJECTIVE: Determine the impact of dietary risk factors on patterns of infection by heat labile toxin-producing Escherichia coli (LT-ETEC). MATERIALS AND METHODS: Ninety-eight infants were followed from birth for one year in Guadalajara, Mexico, beginning in august of 1986. Stool and breast milk samples were collected weekly from infants and their mothers, respectively. Mothers were also interviewed on a weekly basis regarding the health of the infants. Parametric hazard models were fit to durations of different LT-ETEC disease states determined through the analysis of stools. The child's consumption of supplemental foods and liquids as well as specific levels of LT-ETEC-specific breast milk antibodies were included in each model as time-varying covariates. RESULTS: The hazard of LT-ETEC asymptomatic infection increased 400 percent among children who received oats gruel (hazard rate = 4.01; 95% CI 2.77-5.24). The duration of infection was reduced if the child had had a previous LT-ETEC diarrheal episode (2.12; 95% CI 1.74-2.49) but was prolonged if the child consumed herbal teas (0.53; 95% CI 0.27-0.7). Herbal teas and high LT-ETEC-specific breast milk antibody levels each reduced the hazard of symptomatic infection by ninety percent. Symptomatic episodes became asymptomatic more rapidly if a child was given rice water. CONCLUSIONS: Specific weaning foods increase the risk of infection. Breastmilk antibodies and liquid infusions reduce diarrheal disease and infection duration.

Detection of bactericidal antibody in the breast milk of a mother infected with enterohemorrhagic Escherichia coli O157:H7. 
Adachi E, Tanaka H, Toyoda N, Takeda T 
Department of Infectious Diseases Research, National Children's Medical Research Center.
A 21 years-old pregnant woman developed diarrhea, fresh bloody stools and abdominal pain on April 6th 1997 at 32 weeks of gestation, and was admitted to the hospital on April 11th. The stool culture on admission was positive for enterohemorrhagic Escherichia coli (EHEC) O157:H7 (Stx1 and 2). Clinical laboratory data during admission showed only slight elevation of beta-microglobulin and N-acetyl glucosaminidase in the urine, and no neurological or hemolytic symptoms were seen. After the antibiotic and lactobacillus administration, all her symptoms were relieved and no abnormal findings in pregnancy were observed. She delivered a baby girl normally on May 30th. Serum (between 41 and 120 days from the onset) and milk (between 4 and 64 days post partum) samples from the mother, and serum (64 days of age) from a baby and cord blood were obtained to monitor the immune status against EHEC O157:H7 and against Shiga toxins (Stx). Anti-E. coli O157 LPS antibodies (IgA, G and M) were assayed by the ELISA method. Neutralizing anti-Stx antibodies were measured by using ACHN cell cytotoxicity assay. In the colostrum and mature milk, high levels of IgA and IgM, and no IgG antibodies against EHEC O157 LPS were detected. In one of the control colostrum samples obtained from 4 healthy mothers IgA antibody against EHEC O157 LPS was detected. To assess the potency of protection against EHEC O157:H7 by the breast milk, we monitored it by the bactericidal activity for the organism under complement-coincubation experiment, and by the neutralization test for the Stx cytotoxicity. As a result, breast milk samples (both colostrum and mature milk) from a patient were demonstrated to kill the organisms. One of 4 healthy milk samples, showed bactericidal activity though it was negative in O157-LPS antibody. This bactericidal activity seen in one healthy colostrum is possibly due to a nonspecific reaction caused by non-O157 E. coli infection. From these observations, it was suggested that the bactericidal activity was due to the IgM class antibody against EHEC O157:H7. However, the neutralizing antibody against Stx1 and 2 could not be detected in any sample. EHEC infection at late gestation did not cause adverse effects to a fetus, and breastfeeding may have advantage for the protection of a baby against EHEC infection.