American Journal erf Epidemiology
4
Copyright O 1999 by The Johns Hopkins University School of Hygiene and PubOc Health
All rights reserved
LETTERS TO THE EDITOR
RE: "BREASTFEEDING REDUCES RISK OF RESPIRATORY ILLNESS IN INFANTS"
In a recent study, Cushing et al. (1) found that breastfeed-
ing significantly reduced the duration but not the incidence of
respiratory illness during the first 6 months of life, conclud-
ing that breastfeeding reduces respiratory illness in infants.
Inspection of their table 3 shows that they should have disag-
gregated these illnesses. Lower respiratory illnesses were sig-
nificantly less common in the fully breastfed, while upper res-
piratory illnesses were more common in both the partially
breastfed and the fully breastfed. This excess would undoubt-
edly have been statistically significant had otitis media, which
Cushing et al. did not ascertain, been excluded, since there is
considerable evidence that otitis media is more common in
the nonbreastfed. A wider literature review would have shown
that opposite relations between breastfeeding and different
types of respiratory illnesses are a) consistent with the previ-
ous literature (2), which no longer seems confusing and con-
tradictory; b) explicable by a mechanical theory for the pro-
duction of otitis media (3); and c) predicted to occur (2). In
fact, when I encountered their paper I had been checking the
Journal for any infant feeding studies that addressed respira-
tory illness subtypes.
I previously proposed (2) that the main cause of high
infant mortality and morbidity is supine feeding, especially
bottle propping, leading to the "sompe" syndrome. This
causes pooling of liquids in the middle ear, with secondary
reflux down the eustachian tubes into the stomach and
lungs, causing gastroenteritis and pneumonia. Protective
factors in breast milk or pathogens in bottle milk are irrele-
vant. A clear prediction was that sompe infections consistent
with this mechanism would be more common in the bottle-
fed but that nonsompe infections, especially colds, would
not be. My review confirmed this difference. Unexpectedly,
while individual studies were equivocal, in toto they clearly
indicated that colds were more common in the breastfed.
(An ad hoc explanation is the proximity of the noses of
mothers and babies.) This view has not been refuted. A
corollary is that the portal of entry for organisms causing
diarrhea in infants is the nose, not the mouth. Despite many
appeals, this theory also remains unchallenged (4).
I have reviewed later papers on the relative incidence of
sompe and nonsompe infections among the breastfed. In
rural Nicaragua (5), diarrhea and cough, but not colds or
fever in general, were found to be more common during the
previous week in infants with the least amount of breast-
feeding. Diarrhea, but not nasal discharge, was significantly
more common in nonbreastfed infants (6). In an affluent
Danish sample (7), upper respiratory illness was more com-
mon in the breastfed and gastroenteritis and otitis media in
the formula-fed; this difference appears to be significant but
was untested by the authors. In a large US national survey
(8), breastfed infants had significantly less pneumonia and
fewer ear infections or operations. There was no significant
relation with tonsillitis, but there was a hint that asthma and
allergies (including hay fever) were more common in the
breastfed. Holme (9) reported more upper respiratory symp-
toms in breastfed infants. This excess was not an artifact or
a result of confounding, since it was independent of the
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other 12 family or social factors considered. Furthermore,
colds/snuffles/sneezing was the only one of 15 symptom
complexes that was statistically related to feeding mode. In
a study of singletons (10), there was a dose-response rela-
tion between breastfeeding (fuU/partial/nil) and diarrhea,
pneumonia, otitis, colds, and fevers that was consistent with
the sompe mechanism. With siblings, where airborne dis-
ease was likely, otitis, colds, and fevers were, in contrast,
most common in partially breastfed infants.
The finding in this second independent sample replicates
that in the original one (2): Sompe infections, but not non-
sompe infections, are more common among the nonbreast-
fed. Once again, colds are more common in the breastfed.
This finding has been ignored, which is surprising; if cor-
rect, it demolishes at a stroke alternative explanations for
greater morbidity in the bottle-fed. Those explanations
include the following:
1. Antiinfective substances in breast milk, which could
explain varying organism infectivity but not infection
sites.
2. Increased exposure to infective agents, which could
explain gastrointestinal susceptibility but not respira-
tory illness susceptibility.
3. Poorer overall nutrition, which should increase sus-
ceptibility to all infections.
REFERENCES
1. Cushing AH, Samet JM, Lambert WE, et al. Breastfeeding
reduces risk of respiratory illness in infants. Am J Epidemiol
1998;147:863-70.
2. Gordon AG. Respiratory and gastrointestinal infections and
prop feeding. (Letter). Int J Epidemiol 1986;15:138-9.
3. Tully SB, Bar-Haim Y, Bradley RL. Abnormal tympanography
after supine bottle feeding. J Pediatr 1995;126:S105-ll.
4. Gordon AG. Dirty habits. (Letter). Nature 1992;355:196.
5. Marrcro M, Alvarez M, Amador M. Estado actual de lactancia
materna en un area rural de Nicaragua. (In Spanish). Rev
Cubana Pediatr 1985;57:717-30.
6. Miskelly FG, Burr ML, Vaughan-Williams E, et al. Infant
feeding and allergy. Arch Dis Child 1988;63:388-93.
7. Rubin DH, Leventhal JM, Krasilnikoff PA, et al. Relationship
between infant feeding and infectious illness: a prospective
study of infants during the first year of life. Pediatrics 1990;
85:464-71.
8. Ford K, Labbok M. Breast-feeding and child health in the
United States. J Biosoc Sci 1993;25:187-94.
9. Holme CO. Incidence and prevalence of non-specific symp-
toms and behavioural changes in infants under the age of two
years. Br J Gen Pract 1995;45:65-9.
10. Raisler J, Alexander C, O'Campo P. Breast-feeding and infant
illness. Am J Public Health 1999;89:25-30.
A. G. Gordon
32 Love Walk
London SE5 SAD
United Kingdom