By Dr. Linda Folden Palmer
First published on Natural Family Online

Birth-Weight and Pre-term Birth

Representing 16 percent of U.S. infant mortality totals, premature birth and low birth-weight are the second leading diagnoses on death certificates of U.S. infants. While prematurity may lay the foundation for difficulties in tiny infants, the factors that actually take their lives include infection, respiratory distress, unconfirmed necrotizing enterocolitis, circulatory deficiency and diarrhea. These diagnoses are often detectable only with a biopsy, so the listed cause in these cases is often simply prematurity. One study that performed autopsies on a group of extremely low birth-weight infants who had not survived found that infection was the actual primary cause of death for half of the infants. Prematurity was the cause of death predominantly for infants who weighed less than one pound.

Preemies in India who received only preemie formula were found to develop more than twice as many infections as those who received some human milk. Another Indian study on high-risk newborns found that those receiving human milk plus formula suffered twice the infection rate of those receiving only pasteurized human milk and triple the rate of those receiving only raw human milk. A Columbian study found a nearly doubled death rate for low birth-weight infants who were partially or completely formula fed. And a Malaysian study found a huge difference in total infant survival among extremely low birth-weight babies who received expressed breast milk as opposed to those who did not.

A U.S. study performed at George Washington University Hospital found 2.5 times the number of infections among formula-fed infants in the intensive care unit than among those receiving human milk. Another study at Georgetown University Medical Center also found more than double the number of infections in very low birth-weight infants not receiving human milk. A San Diego study found twice as many infections in pre-term, formula-fed infants compared with infants who received human milk.

As shown in many other studies, the extent and severity of infection among pre-term and low birth-weight infants are generally greater in formula-fed infants as well. One study gives a solid example for preemies, finding respiratory infections among U.S. formula-fed preemies to run six times as many days as those in their breastfed counterparts.

Pre-term Infant Illness and Death Rates (57-64)

Exclusive feeding of raw breast milk is not always an option for premature infants, although it is common in some hospitals with excellent support. Sometimes, less-effective pasteurized breast milk is used and often fortifiers are added. Several studies show decreased survival for infants fed milk with added fortifiers as opposed to those fed unfortified milk, (65-68) but the picture is complex and the choices of fortifiers vary greatly.

And finally, it is worth noting that the eye damage that can occur in very low birth-weight infants, retinopathy of prematurity, occurs only half as often in infants who receive some breast milk. (69) Even a disorder as apparently unrelated to feeding methods as inguinal hernia has been discovered to occur twice as often in artificially fed infants and even more frequently when compared with infants who are exclusively breastfed.70

Congenital Abnormalities

Twenty percent of U.S. infant deaths are attributed to birth defects. The most common potentially lethal birth defects include heart disorders, various chromosomal or genetic defects and underdeveloped lungs. In terms of infant formula’s impact, we have the least amount of statistical information in this category. However, many factors suggest that formula-fed infants with congenital abnormalities have smaller chances of survival than their breastfed counterparts.

While death certificates often list the initial abnormality as the cause of death, infection is actually the final factor in many of these deaths. We have already seen how drastically infection rates and deaths are reduced by breastfeeding. It is clear that the youngest and weakest infants are the ones who are most strongly endangered by infant formula’s inadequacies.

Studies suggest that formula-fed infants suffer inferior blood oxygenation and higher blood pressure as well as more episodes of apnea (cessation of breathing for a short time) than their breastfed counterparts. While no studies compare the actual survival of such infants in the United States, it is obvious that some proportion of babies with congenital heart abnormalities is being seriously disadvantaged by formula feedings. Artificially fed infants with heart defects requiring surgery are less likely to live until their surgery and less likely to recover from surgery’s challenges.

A wide variety of common birth defects have been shown to have better survival rates among breastfed infants, although the actual figures are not available. Most birth defects have not been specifically studied in this regard. The background information, nonetheless, is striking.

For example, infants born with phenylketonuria (PKU), a defect in handling a certain protein in the diet, need specialized supplementation with breast milk in order to prevent mental retardation and other difficulties. Yet a study demonstrated that infants who had been breastfed before being diagnosed with PKU fared far better than those who had been fed on formula. (71) The greatest complications for infants with cystic fibrosis are lung infection, decreased oxygenation and malnutrition--all of which are recognized to be complicated by formula feeding. (72) The negative impact of formula on neurological development has been demonstrated in healthy infants. (73-76) One study that quantified the effect reported double the amount of neurological "non-normality" in formula-fed infants. (77) It is reasonable to assume that neurological damage or problems stemming from birth disorders can be exacerbated by artificial feeding.

Clearly, feeding choice may have a significant impact on the survival of infants born with various defects, although there is not enough information available to render an actual ratio of survival.

Complications of Pregnancy and Birth

Complications of pregnancy and birth produce a wide range of injuries and problems for babies. Some certainly pose no hope of survival. Infection, insufficient neurological recovery and inadequate oxygenation lead to many infant deaths. Artificial feeding certainly has some degree of impact on mortality in these cases. Based on a lack of further detailed evidence, we will apply a very modest number to figures for increased risk of death for formula-fed infants in this category.

Accidents

It seems logical that accidents happen equally among artificially and naturally fed infants. Figures bear this out. One paper actually measured accidental injuries between breast- and formula-fed infants, finding an equal number in both.78

Examining the numbers

So now we are left to examine artificial feeding’s actual impact on all American babies. First, we note that there should be a relationship dictating that if rates for a certain disease are doubled by formula feeding, for instance, then death rates for that disease may also be somewhere in the neighborhood of doubled when compared with rates for breastfed infants. In fact, the evidence suggests that the death rates would be even higher. While formula feeding may result in twice as many episodes of a certain illness, a great number of studies demonstrate that each of these episodes are also longer and more severe. This would suggest that the rate of death among artificially fed infants from various causes would actually be higher than the rates that the various illnesses occur.

The reported percentages of U.S. infants dying from each cause include a certain number of infants who were breastfed and a portion who were formula-fed. Because formula feeding’s impact is much more or less influential in some disorders than others, we need to weigh each category accordingly. (This exercise will account for the assumption that a lower proportion of infants who died from congenital abnormalities, for instance, were formula-fed infants than the proportion who died from SIDS.) Because two-thirds of all infants die in the first month, and because exclusive breastfeeding runs about 50 percent during the first month, this number can be used in the calculations to help weigh the greater or lesser impact of breastfeeding for each cause.

2001 U.S. Breastfeeding Rates (79,80)

An overall risk rate of infant death for formula-fed infants has been selected conservatively based on the available information presented in this paper for each cause of death in the table below. Assuming that 50 percent of the total infants born were breastfed, we can calculate formula-fed and breastfed infant death rates and totals for each cause.

Because one-third of the deaths actually occurred as the percentage of infants breastfeeding was dropping to a much smaller number, the use of 50 percent throughout the calculations keeps the resultant finding very conservative. Although the literature reiterates time and again how the extent, severity and frequency of disease is greater in formula-fed infants, I have only taken this factor into account in an extremely conservative manner in instances where the literature provides solid numerical examples. In other instances where this aspect is not clearly demonstrated, I have not used this factor at all. Again, this effort keeps the final quotient conservative. Finally, the ratios from many studies used are for full formula feeding versus any amount of breastfeeding. Some of these ratios would be much higher if formula feeding were compared to exclusive breastfeeding. This factor again keeps our final conclusion conservative.

Here’s the math

There are 4,000,000 births annually in the United States. Using 50 percent as the number of infants who have actually been breastfed, the number of infants breastfed (B) equals 2,000,000. The number of formula-fed (F) infants also equals 2,000,000.

Let's apply this formula to congenital abnormalities. Clearly, feeding's impact in this category could be significant, but there is not enough solid statistical evidence to say for sure. If we modestly assume a 50 percent higher death rate for the 50 percent of formula-fed infants, the number of breastfed infants who died would be 2,200. The number of formula-fed who died would be 3,300. If all of the infants had actually been breastfed, then the total number of deaths would be 4,400--a savings of 1,100 lives.

The relative risk for formula feeding in other categories was much more clearly defined by the studies. Conservative but appropriate rates were selected, as seen in the table below.

Calculating Formula's Final Impact

Infant Mortality Rates (IMR) is the number of infant deaths per 1,000 live births, from 0 to 12 months of age.

Based on the current U.S. infant death rate of 6.75 and an average breastfeeding rate of 50 percent, the American infant mortality rate would climb to 9.4 if all infants were formula-fed and would drop to 4.7 if all were breastfed. Twenty-two nations with high rates of breastfeeding have infant mortality rates below 5, while the U.S. ranks higher in infant death than 41 other nations. (81) Clearly, lower rates for the United States are a possibility.

The ugly truth about formula

From the above statistics, we see that formula feeding costs American babies more than four additional lives per thousand. The final relative risk for formula feeding comes out to 2--that’s double the risk of death for American infants who are fed with formula, compared with babies who are fed naturally.

A multitude of studies demonstrate that when breastfeeding is accompanied by formula supplementation, illness and death rates are much closer to those of babies who are fully formula-fed. Studies also reveal conclusively that the longer breastfeeding lasts, the greater the measurable difference in illness and death rates.

Answering the detractors

Criticisms are often spread about studies that find increased illness and death rates associated with formula feeding. For just this reason, each later study aggressively attempts to take into account any factors that have been purported as distorting previous study outcomes. These research papers address as many aspects as possible, from maternal education, to smoking, to income level, to day care usage and many more possibilities. The results continue to reveal the risks of formula feeding.

It’s commonly said that formula feeding does not risk lives in industrialized nations where education and medical advances prevent increased deaths. The evidence is quite to the contrary. Some insist that the blame for the United States’ relatively high infant death rate lies with underprivileged communities. Again, it has been shown that elevated death rates among U.S. blacks cannot be attributed to poverty. Hispanic Americans rank similarly to African-American populations for socio-economic factors, but they match non-Hispanic whites in their lower infant mortality rates. The difference is not socio-economic; rather, it’s in rates of formula use versus breastfeeding. (82-84)

A New York study sought to establish the connection between education, income and infant survival. It concluded strongly that the number of illnesses is increased by two to three times in formula-fed babies regardless of socioeconomic status or level of parental education. (85) A later study in Israel confirmed the effects of formula feeding across all classes and education levels. (86) The most recent analysis of this issue, again performed in the United States, reiterated that higher illness rates among formula-fed or formula-supplemented infants "did not differ among income groups." (87)

And beyond the first year

While the extent of breast milk’s health protection declines with age, a great number of studies demonstrate the continued survival advantage of breastfeeding through the second year and beyond. A World Health Organization study of less-developed countries found a doubled risk of death in the second year of life for those weaned prematurely or never receiving breast milk. (88) A study in The Netherlands found a strong correlation between the extent of breastfeeding and the number of illnesses in children. Significant protection from breastfeeding was noted during the first three years of life. (89) Other studies show a sizeable increase in illnesses throughout all of childhood for those who were never breastfed or prematurely weaned. (90-92) In fact, an increased risk of death throughout life has been well documented for people who were formula-fed. Higher blood pressure, more heart disease, obesity, diabetes and artery disease, a nearly doubled rate of Crohn’s disease and tripled rates of celiac disease have all been associated with early formula feeding. (93-105)

What your doctor doesn’t tell you

Pediatricians spend much time frightening parents with 1 in 100,000 risks from vaccine-preventable diseases when parents question the utility and safety of vaccines. "Would you want to risk the life of your child?" they demand. Yet these very same professionals offer formula samples with the other hand--when the magnitude of health risks associated with the use of formula is 500 times greater.

Parenting is all about making choices and weighing risks and benefits. Many parents need to make the riskier choice of formula feeding in order to balance other factors that benefit the family. Yet some parents who have lost their children, possibly based on pediatric advice condoning or encouraging formula-feeding, would surely wish that they had been informed of the very real risks related to using formula.

Dr. Linda Folden Palmer consults and lectures on natural infant health, optimal child nutrition and attachment parenting. After running a successful chiropractic practice focused on nutrition and women's health for more than a decade, Linda's life became transformed eight years ago by the birth of her son. Her research into his particular health challenges led her to write Baby Matters: What Your Doctor May Not Tell You About Caring for Your Baby. Extensively documented, this healthy parenting book presents the scientific evidence behind attachment parenting practices, supporting baby's immune system, preventing colic and sparing drug usage. You can visit Linda's Web site at www.babyreference.com.