Immunology of breast milk

Imunologia do leite materno

Patricia Palmeira Magda Carneiro-Sampaio About the authors

Summary

In the critical phase of immunological immaturity of the newborn, particularly for the immune system of mucous membranes, infants receive large amounts of bioactive components through colostrum and breast milk. Colostrum is the most potent natural immune booster known to science. Breastfeeding protects infants against infections mainly via secretory IgA (SIgA) antibodies, but also via other various bioactive factors. It is striking that the defense factors of human milk function without causing inflammation; some components are even anti-inflammatory. Protection against infections has been well evidenced during lactation against, e.g., acute and prolonged diarrhea, respiratory tract infections, including otitis media, urinary tract infection, neonatal septicemia, and necrotizing enterocolitis. The milk’s immunity content changes over time. In the early stages of lactation, IgA, anti-inflammatory factors and, more likely, immunologically active cells provide additional support for the immature immune system of the neonate. After this period, breast milk continues to adapt extraordinarily to the infant’s ontogeny and needs regarding immune protection and nutrition. The need to encourage breastfeeding is therefore justifiable, at least during the first 6 months of life, when the infant’s secretory IgA production is insignificant.

Keywords
human milk; secretory IgA antibodies; infections; term newborn; preterm newborn

Resumo

Na fase crítica de imaturidade imunológica do recém-nascido, em especial do sistema imune de mucosas, o lactente recebe grandes quantidades de componentes bioativos através do colostro e do leite materno. O colostro é o reforço imunológico natural mais potente conhecido pela ciência. O aleitamento materno protege o lactente de infecções principalmente por meio dos anticorpos IgA secretores (IgAS), mas também por meio de vários outros fatores bioativos. É surpreendente que os fatores de defesa do leite humano ajam sem causar inflamação e alguns componentes são, de fato, anti-inflamatórios. A proteção contra infecções tem sido bem evidenciada durante a lactação, combatendo, por exemplo, diarreia aguda e prolongada, infecções do trato respiratório, incluindo otite média, infecção do trato urinário, sepse neonatal e enterocolite necrosante. O conteúdo imunológico do leite evolui ao longo do tempo: nas fases iniciais de lactação, IgAS, fatores anti-inflamatórios e, mais provavelmente, as células imunologicamente ativas provêm ajuda adicional para o sistema imune imaturo do neonato. Depois desse período, o leite materno continua a adaptar-se extraordinariamente à ontogenia infantil, às suas necessidades de proteção imune e nutricionais. Entende-se, portanto, a necessidade de se estimular o aleitamento materno pelo menos durante o primeiro semestre de vida, período em que a produção própria de IgA secretória é ainda pouco significativa.

Palavras-chave
leite humano; anticorpos IgA secretores; infecções; recém-nascido a termo; recém-nascido pré-termo

INTRODUCTION

The neonatal period is particularly critical because after birth babies are immediately exposed to a large number of microorganisms. The high morbidity and mortality rates observed during the first months of life due to infectious diseases such as otitis media, upper and lower respiratory tract infections, gastroenteritis, sepsis, and meningitis are due, among other factors, to significant quantitative and qualitative deficiencies in various components of the immune system (Table 1).11 Lewis DB, Wilson CB. Developmental immunology and role of host defenses in neonatal susceptibility to infection. In: Remington JS, Klein JO, Wilson CB, Nizet V, Maldonado YA, editors. Infectious diseases of the fetus and newborn infant. 7.ed. Philadelphia: Saunders; 2011. p.83-169. To compensate for this immunological immaturity inherent to the fetal and neonatal periods and the first months of life, nature has developed adoptive protection mechanisms provided by the mother, represented by i) the transplacental transfer of antibodies, ii) anti-infective resistance factors in the amniotic fluid, and iii) in extrauterine life, colostrum and milk.22 Hanson LA, Korotkova M, Lundin S, Håversen L, Silfverdal SA, Mattsby-Baltzer I, et al. The transfer of immunity from mother to child. Ann N Y Acad Sci. 2003; 987:199-206.

TABLE 1
Immature components of the immune system at birth and during childhood.

Colostrum (milk produced during the first days after birth), in addition to being a rich source of nutrients, contains high concentrations of various protective factors with anti-infective action, such as enzymes (lysozyme, lactoferrin etc.), immunoglobulins, cytokines, complement system components, leukocytes, oligosaccharides, nucleotides, lipids, and hormones that interact with each other and with the mucous membranes of the digestive and upper respiratory tracts of infants, providing passive immunity as well as stimulation for the development and maturation of the infant’s immune system (Table 2).33 Hosea Blewett HJ, Cicalo MC, Holland CD, Field CJ. The immunological components of human milk. Adv Food Nutr Res. 2008; 54:45-80.

TABLE 2
Bioactive factors of colostrum and breast milk.

The antimicrobial factors present in colostrum and milk have some common characteristics, such as resistance to degradation by digestive enzymes, protection of the mucosal surfaces and elimination of bacteria without initiating inflammatory reactions.44 Hanson LA. Symposium on ‘Nutrition in early life: new horizons in a new century’. Session 1: Feeding and infant development. Breast-feeding and immune function. Proc Nutr Society. 2007; 66:384-96. The presence of various bioactive components in breast milk with multifunctional and anti-inflammatory properties provides wide evidence to support the recommendation of exclusive maternal breastfeeding (defined as the exclusive consumption of breast milk and no other liquids or food) within one hour after birth and during the first 6 months of life for all healthy women and children.55 Morrow AL, Rangel JM. Human milk protection against infectious diarrhea: Implications for prevention and clinical care. Semin Pediatr Infect Dis. 2004; 15(4):221-8.

PROTEIN COMPONENTS OF HUMAN MILK

Secretory IgA antibodies

Human milk has antibodies directed at numerous pathogens with which the mother has had contact throughout life, somehow representing an immunological memory.66 Hanson LA. Breastfeeding provides passive and likely long-lasting active immunity. Ann Allergy Asthma Immunol. 1998; 81(6):523-37. These antibodies constitute the majority of the protein content of this secretion in the first days of lactation. Antibody concentrations fall throughout lactation; however, the amount of immunoglobulins received by the child remains unchanged due to the increased milk intake.77 Hanson LA, Korotkova M. The role of breastfeeding in prevention of neonatal infection. Semin Neonatol. 2002; 7(4):275-81. Although all immunoglobulin isotypes are found in colostrum and milk, secretory IgA (SIgA) is considered the most important, both in relation to its concentration and biological properties.88 Goldman AS, Thorpe LW, Goldblum RM, Hanson LA. Anti-inflammatory properties of human milk. Acta Paediatr Scand. 1986; 75(5):689-95. SIgA antibodies in breast milk are essential in the defense of the mucous membranes. These antibodies effectively prevent the entry of microorganisms in the tissues, they are anti-inflammatory and do not consume energy during the reaction.99 Lepage P, Van de Perre P. The immune system of breast milk: antimicrobial and anti-inflammatory properties. Adv Exp Med Biol. 2012; 743:121-37.,1010 Brandtzaeg P. The mucosal immune system and its integration with the mammary glands. J Pediatr. 2010; 156(2 Suppl):S8-15.

IgM antibodies are the second most abundant immunoglobulin in human colostrum, at concentrations of up to 2.5 mg/mL. High avidity IgM antibodies reactive with viruses and bacteria may play an important role in protecting the mucosal surfaces of infants. IgG is found at low concentrations in human milk, around 0.1 mg/mL (10% of serum values) and, in addition to neutralizing activity, has opsonizing activity that can activate the complement system and antibody-dependent cytotoxicity, which is not thought to be strongly present on the infants’ mucosal surfaces.22 Hanson LA, Korotkova M, Lundin S, Håversen L, Silfverdal SA, Mattsby-Baltzer I, et al. The transfer of immunity from mother to child. Ann N Y Acad Sci. 2003; 987:199-206.

SIgA is responsible for 80 to 90% of total immunoglobulins in human milk, and infants fed exclusively with breastfed receive around 0.3 g/kg/day of this protein, where only around 10% is absorbed in the intestines and transferred to the bloodstream, that is, its action is fundamentally local.1111 Brandtzaeg P, Kiyono H, Pabst R, Russell MW. Terminology: nomenclature of mucosa-associated lymphoid tissue. Mucosal Immunol. 2008; 1(1):31-7.,1212 Carlsson B, Hanson LA. Immunologic effects of breast-feeding on the infant. In: Ogra P, Lamm ME, Strober W, McGhee JR, Bienestock J, editors. Handbook of Mucosal Immunology. London: Academic Press; 1994. p.653-66. The role of SIgA and, to a lesser extent, SIgM is to act locally on the newborn’s intestine as a first line of defense directed at foreign antigens. As a result, SIgA molecules remain active throughout the newborn’s gastrointestinal tract and impact the binding of commensal or pathogenic microorganisms, toxins, viruses, and other antigenic materials, such as lipopolysaccharide (LPS), preventing their adherence and penetration into the epithelium without triggering inflammatory reactions that could be harmful to the newborn, a mechanism known as immune exclusion. High-affinity dimeric IgA and pentameric IgM antibodies transported by the pIgR may even inactivate viruses (e.g. rotavirus and influenza) within epithelial cells and carry these pathogens and their products back into the lumen, thereby avoiding cytolytic damage to the epithelium.1313 Johansen FE, Brandtzaeg P. Transcriptional regulation of the mucosal IgA system. Trends Immunol. 2004; 25(3):150-7. In individuals with selective IgA deficiency, SIgM antibodies are of great importance, since they constitute a compensation mechanism for the lack of SIgA in the mucous membranes, and are present at high levels in these secretions.1414 Palmeira P, Costa-Carvalho BT, Arslanian C, Pontes GN, Nagao AT, Carneiro-Sampaio MM. Transfer of antibodies across the placenta and in breast milk from mothers on intravenous immunoglobulin. Pediatr Allergy Immunol. 2009; 20(6):528-35.

Figure 1 shows an immunochemical test (Western blotting) in which IgA antibodies from the colostrum remain viable in the feces of an exclusively breastfed newborn, and, in this particular case, are able to bind to antigens originating from enteropathogenic Escherichia coli.1515 Carbonare SB, Silva ML, Palmeira P, Carneiro-Sampaio MM. Human colostrum IgA antibodies reacting to enteropathogenic Escherichia coli antigens and their persistence in the faeces of a breastfed infant. J Diarrhoeal Dis Res. 1997; 15(2):53-8. This technique demonstrates that SIgA antibodies were not destroyed by digestion and that they protect the entire intestinal tract. Thus, the effect of dimeric IgA antibodies produced locally would promote the inhibition of excessive colonization of microorganisms from the mucous membrane, as well as the penetration of soluble antigens.

Figure 1
Western blotting reaction performed with enteropathogenic E. coli (EPEC) antigens that reacted with samples of human colostrum (samples A, B, C and E) and a stool sample from an exclusively breastfed five-day old newborn (D) (colostrum – sample E). Note that there are distinct EPEC antigen recognition patterns in the colostrum samples from different mothers (A-C). Sample D reveals that there are intact IgA antibodies in the feces of the breastfed newborn that recognize certain EPEC antigens, including intimin (94kDa), an important bacterial adhesin.1515 Carbonare SB, Silva ML, Palmeira P, Carneiro-Sampaio MM. Human colostrum IgA antibodies reacting to enteropathogenic Escherichia coli antigens and their persistence in the faeces of a breastfed infant. J Diarrhoeal Dis Res. 1997; 15(2):53-8.

Free secretory component

Free secretory component (SC), which is particularly abundant in breast milk, can block epithelial adhesion and therefore limit infection by enterotoxigenic Escherichia coli,1616 de Araújo AN, Giugliano LG. Lactoferrin and free secretory component of human milk inhibit the adhesion of enteropathogenic Escherichia coli to HeLa cells. BMC Microbiol. 2001; 1:25.Salmonella typhimurium,1717 Bessler HC, de Oliveira IR, Giugliano LG. Human milk glycoproteins inhibit the adherence of Salmonella typhimurium to HeLa cells. Microbiol Immunol. 2006; 50(11):877-82. and pneumococcus,1818 Hammerschmidt S, Talay SR, Brandtzaeg P, Chhatwal GS. SpsA, a novel pneumococcal surface protein with specific binding to secretory immunoglobulin A and secretory component. Mol Microbiol. 1997; 25(6):1113-24. as well as inhibit the effect of bacterial toxins such as Clostridium difficile toxin A.1919 Dallas SD, Rolfe RD. Binding of Clostridium difficile toxin A to human milk secretory component. J Med Microbiol. 1998; 47(10):879-88.

Lysozyme and lactoferrin

Major enzymes present in colostrum include lysozyme and lactoferrin. Lysozyme is an enzyme capable of degrading the outer wall of Gram-positive bacteria, as it hydrolyzes β-1,4 bonds from the residues of N-acetylmuramic acid and N-acetylglucosamine.2020 Chipman DM, Sharon N. Mechanism of lysozyme action. Science. 1969; 165(3892):454-65. Lysozyme also has the ability to kill Gram-negative bacteria in vitro, acting synergistically with lactoferrin, which binds to the lipopolysaccharide in the outer bacterial membrane, removing it and allowing lysozyme to access and degrade the internal proteoglycan matrix of the membrane, thereby killing the bacteria.2121 Ellison RTJ, Giehl TJ. Killing of Gram-negative bacteria by lactoferrin and lysozyme. J Clin Invest. 1991; 88(4):1080-91. Lysozyme is also reported as having antiviral activity.2222 Lee-Huang S, Huang PL, Sun Y, Huang PL, Kung HF, Blithe DL, et al. Lysozyme and RNases as anti-HIV components in beta-core preparations of human chorionic gonadotropin. Proc Natl Acad Sci U S A. 1999; 96(6):2678-81.

SIgA and lactoferrin correspond to 26% of the protein content of breast milk, resulting in a lactoferrin concentration of approximately 1 g/L in mature milk and 7 g/L in colostrum.2323 Houghton M, Santoso H, Soetjiningsih, Gracey M. Lactoferrin concentrations in the breast milk of Indonesian mothers. Paediatr Indones. 1985; 25(9-10):163-6. It has a bacteriostatic function in the intestinal mucosa of the newborn, by binding with the iron present in the child’s digestive system, preventing the growth of various pathogens. In addition, it has a direct cytotoxic effect against bacteria, viruses, and fungi and carries out immunomodulatory functions, helping to limit excessive immune responses by blocking many inflammatory cytokines such as IL-1β, IL-6, TNF-α and IL-82424 Mattsby-Baltzer I, Roseanu A, Motas C, Elverfors J, Engberg I, Hanson LA. Lactoferrin or a fragment thereof inhibits the endotoxin-induced interleukin-6 response in human monocytic cells. Pediatr Res. 1996; 40(2):257-62.

25 Elass E, Masson M, Mazurier J, Legrand D. Lactoferrin inhibits the lipopolysaccharide-induced expression and proteoglycan-binding ability of interleukin-8 in human endothelial cells. Infect Immun. 2002; 70(4):1860-6.
-2626 Håversen LA, Baltzer L, Dolphin G, Hanson LA, Mattsby-Baltzer I. Anti-inflammatory activities of human lactoferrin in acute dextran sulphate-induced colitis in mice. Scand J Immunol. 2003; 57(1):2-10. while also stimulating the activity and development of the child’s immune system.2727 Hashizume S, Kuroda K, Murakami H. Identification of lactoferrin as an essential growth factor for human lymphocytic cell lines in serum-free medium. Biochim Biophys Acta. 1983; 763(4):377-82. Part of lactoferrin’s activity is attributed to the formation of lactoferricin, a potent cationic peptide with bactericidal activity formed during the digestion of lactoferrin.2828 Tomita M, Bellamy W, Takase M, Yamauchi K, Wakabayashi H, Kawase K. Potent antibacterial peptides generated by pepsin digestion of bovine lactoferrin. J Dairy Sci. 1991; 74(12):4137-42.

Lactoperoxidase

Lactoperoxidase, in the presence of hydrogen peroxide (formed in small amounts by the cells), catalyzes the oxidation of thiocyanate (present in saliva), forming hypothiocyanate that can kill both Gram-positive,2929 Steele WF, Morrison M. Antistreptococcal activity of lactoperoxidase. J Bacteriol. 1969; 97(2):635-9. as well as Gram-negative bacteria.3030 Björck L, Rosén CG, Marshall V, Reiter B. Antibacterial activity of lactoperoxidase system in milk against pseudomonas and other Gram-negative bacteria. Appl Microbiol. 1975; 30(2):199-204.

k-Casein

k-casein, a small subunit of casein present in breast milk, is a glycoprotein that contains charged sialic acid residues and presents inhibitory activity for adhesion by Helicobacter pylori to the human gastric mucosa by acting as a soluble receptor analogue of epithelial cell surfaces.3131 Lönnerdal B. Nutritional and physiologic significance of human milk proteins. Am J Clin Nutr. 2003; 77(6):1537S-43S.

α-Lactalbumin

It has been shown that various hydrolysis products of casein and α-lactalbumin have antimicrobial activity against E. coli, Klebsiella pneumoniae, staphylococcus, streptococcus, and C. albicans.3232 Pellegrini A, Thomas U, Bramaz N, Hunziker P, von Fellenberg R. Isolation and identification of three bactericidal domains in the bovine alpha-lactalbumin molecule. Biochim Biophys Acta. 1999; 1426(3):439-48. α-Lactalbumin in human milk also has the property of binding to oleic acid and, after the release of Ca2+ ions and conformational change, it forms a compound called HAMLET (human α-lactalbumin made lethal to tumor cells).3333 Hallgren O, Aits S, Brest P, Gustafsson L, Mossberg AK, Wullt B, et al. Apoptosis and tumor cell death in response to HAMLET (human alpha-lactalbumin made lethal to tumor cells). Adv Exp Med Biol. 2008; 606:217-40.

Haptocorrin

It has been suggested that the haptocorrin protein present in human milk has the property of binding to vitamin B12, making it inaccessible for bacterial growth. It has been shown that both haptocorrin exposed to digestive enzymes as well as undigested haptocorrin inhibit the growth of a strain of enteropathogenic E. coli at similar levels, suggesting this protein contributes to defense against infections in breastfed children.3434 Adkins Y, Lönnerdal B. Potential host-defense role of a human milk vitamin B-12-binding protein, haptocorrin, in the gastrointestinal tract of breastfed infants, as assessed with porcine haptocorrin in vitro. Am J Clin Nutr. 2003; 77(5):1234-40.

Osteoprotegerin

Osteoprotegerin is found in the epithelial cells of the mammary gland and in human milk at concentrations up to 1,000 times higher than those found in human serum.3535 Vidal K, van den Broek P, Lorget F, Donnet-Hughes A. Osteoprotegerin in human milk: A potential role in the regulation of bone metabolism and immune development. Pediatr Res. 2004; 55(6):1001-8. It can bind to TNF-related apoptosis-inducing ligand (TRAIL) and induce caspase-dependent apoptosis, especially in Th1 cells, which is supposed to be important to regulate the balance of Th1/Th2 in the development of the immune system in newborns.3636 Vidal K, Serrant P, Schlosser B, van den Broek P, Lorget F, Donnet-Hughes A. Osteoprotegerin production by human intestinal epithelial cells: a potential regulator of mucosal immune responses. Am J Physiol Gastrointest Liver Physiol. 2004; 287(4):G836-G44.

Soluble CD14 (sCD14)

Colostrum and breast milk contain high levels of the sCD14 molecule, exceeding the concentration found in the serum more than 20 times.3737 Blewett HJH, Cicalo MC, Holland CD, Field CJ. The immunological components of human milk. Adv Food Nutr. 2008; 54:45-80. This component affects the modulation of innate and adaptive immune responses in the intestine during bacterial colonization and thus controls homeostasis in the newborn’s intestine.3838 Labéta MO, Vidal K, Nores JE, Arias M, Vita N, Morgan BP, et al. Innate recognition of bacteria in human milk is mediated by a milk-derived highly expressed pattern recognition receptor, soluble CD14. J Exp Med. 2000; 191(10):1807-12.

HORMONES AND GROWTH FACTORS

Hormones and growth factors are among the bioactive components found in human milk. Some hormones may have a direct effect on breast and on milk production (insulin, steroids, prolactin), while others may contribute to the growth, differentiation, and development of various tissues in the infant.3939 Lawrence RM, Pane CA. Human breast milk: current concepts of immunology and infectious diseases. Curr Probl Pediatr Adolesc Health Care. 2007; 37(1):7-36. The various growth factors (epidermal growth factor, nerve growth factor, insulin, TGF-α, TGF-β, relaxin and insulin-like growth factor) particularly influence the growth and development of the gastrointestinal tract but may have some effect on glucose levels and systemic growth.

Colostrum and breast milk contain colony stimulating factors (CSF), responsible for regulating the proliferation, differentiation, and survival of milk neutrophils and macrophages, such as GM-CSF (granulocyte-macrophage colony stimulating factor), M-CSF (macrophage colony stimulating factor) and G-CSF (granulocyte-colony stimulating factor). GM-CSF,4040 Skansén-Saphir U, Lindfors A, Andersson U. Cytokine production in mononuclear cells of human milk studied at the single cell level. Pediatr Res. 1993; 34(2):213-6. M-CSF4141 Hara T, Irie K, Saito S, Ichijo M, Yamada M, Yanai N, et al. Identification of macrophage colony-stimulating factor in human milk and mammary epithelial cells. Pediatr Res. 1995(4 Pt 1); 37:437-43. and G-CSF have been isolated from human milk at concentrations ranging from 45 to 1551 pg/mL,4242 Gilmore WS, McKelvey-Martin VJ, Rutherford S, Strain JJ, Loane P, Kell M, et al. Human milk contains granulocyte colony stimulating factor. Eur J Clin Nutr. 1994; 48(3):222-4. while the plasma concentrations are significantly lower and less variable (10.5±4.5 pg/mL).

CYTOKINES AND CHEMOKINES

Cytokines in human milk may have an immunostimulatory or immunomodulatory effect on phagocytic cells and on lymphocytes involved in developing the specific immune response of the child, acting in the prevention of allergies and hypersensitivities. They may also target the cells of breast milk itself, promoting activation, phagocytosis stimulation and antigen presentation; inducing growth, differentiation and production of immunoglobulin by B cells; increasing thymocyte proliferation; and the suppression of IgE production.4343 Garofalo R. Cytokines in human milk. J Pediatr. 2010; 156(2 Suppl):S36-40.

Certain cytokines such as IL-6 and TNF-α are associated with regulating the development and functions of the mammary gland, and others, such as IL-1 and IFN-g, influence the production of defense agents, SIgA, or other cytokines by the mammary gland.4444 Basolo F, Fiore L, Fontanini G, Giulio P, Simonetta C, Falcone V, et al. Expression of response to interleukin 6 (IL6) in human mammary tumors. Cancer Res. 1996; 56(13):3118-22. IL-10 is an important anti-inflammatory and immunoregulatory cytokine present in high concentration in both the aqueous phase and in the lipid layer of breast milk. Like IL-10, TGF-β (transforming growth factor-β) has important immunomodulatory properties, such as stimulating intestinal maturation and defense of the newborn; involvement in switching from IgM to IgA in B lymphocytes; immunoglobulin production in the mammary gland and the gastrointestinal tract of the newborn, and induction of oral tolerance. Its suppressive effect on T cells has been associated with a possible role in the prevention, or at least suppression of the onset of allergic diseases in breastfed infants.4545 Verhasselt V. Neonatal tolerance under breastfeeding influence: the presence of allergen and transforming growth factor-b in breast milk protects the progeny from allergic asthma. J Pediatr. 2010; 156(2 Suppl):S16-20.

CXC chemokines, potent activators of neutrophils, are present in large quantities in breast milk, and have chemotactic activity for intraepithelial lymphocytes and play an important role in the host’s defense against bacterial and viral infections.4646 Keeney SE, Schmalstieg FC, Palkowetz KH, Rudloff E, Le BM, Goldman AS. Activated neutrophils and neutrophil activators in human milk: increased expression of CD11b and decreased expression of L-selectin. J Leukoc Biol. 1993; 54(2):97-104.

47 Ebert E. IL-8, RANTES, and GRO are chemotactic for intraepithelial lymphocytes (IEL). Gastroenterology. 1995; 108(4):A813.
-4848 Cocchi F, DeVico AL, Garzino-Demo A, Arya SK, Gallo RC, Lusso P. Identification of RANTES, MIP-1 alpha, and MIP-1 beta as the major HIV suppressive factors produced by CD8+ T cells. Science. 1995; 270(5243):1811-5.

LIPIDS

The fat content of breast milk is 3-4 g/L in colostrum and transition and mature milk, with 93-97% of lipids in the form of triglycerides. It has been demonstrated that in addition to their nutritional and development benefits, milk fats perform antimicrobial activity in the intestine of infants.4949 German JB, Dillard CJ. Composition, structure and absorption of milk lipids: a source of energy, fat-soluble nutrients and bioactive molecules. Crit Rev Food Sci Nutr. 2006; 46(1):57-92. Free fatty acids (FFAs) and monoglycerides, the digestive products of triglycerides, have a lytic effect on several viruses.5050 Isaacs CE. The antimicrobial function of milk lipids. Adv Nutr Res. 2001; 10:271-85.

51 Thormar H, Isaacs CE, Brown HR, Barshatzky MR, Pessolano T. Inactivation of enveloped viruses and killing of cells by fatty acids and monoglycerides. Antimicrob Agents Chemother. 1987; 31(1):27-31.
-5252 Welsh JK, Skurrie IJ, May JT. Use of Semliki forest virus to identify lipid-mediated antiviral activity and anti-alphavirus immunoglobulin A in human milk. Infect Immun. 1978; 19(2):395-401. FFAs also have an antiprotozoal effect, particularly against Giardia. The passive protection of breast milk may also be provided by components present in the milk fat globules, such as mucins, which can prevent the binding of pathogens in the stomach and small intestine of the infant.5353 Schroten H, Hanisch FG, Plogmann R, Hacker J, Uhlenbruck G, Nobis-Bosch R, et al. Inhibition of adhesion of S-fimbriated Escherichia coli to buccal epithelial cells by human milk fat globule membrane components: a novel aspect of the protective function of mucins in the nonimmunoglobulin fraction. Infect Immun. 1992; 60(7):2893-9.,5454 Kvistgaard AL, Pallesen LT, Arias CF, López S, Petersen TE, Heegaard CW, et al. Inhibitory effects of human and bovine milk constituents on rotavirus infections. J Dairy Sci. 2004; 87(12):4088-96.

NUCLEIC ACIDS

Nucleotides, nucleosides, nucleic acids, and related products constitute around 15 to 20% of the non-protein nitrogen content in breast milk. In vitro and in vivo experiments suggest a variety of different functions for ingested nucleotides: increasing iron absorption; increasing the growth of Bifidobacterium; increasing the growth, development, and repair of the gastrointestinal mucosa; and increasing NK cell activity and IL-2 production.5555 Pickering LK, Granoff DM, Erickson JR, Masor ML, Cordle CT, Schaller JP, et al. Modulation of the immune system by human milk and infant formula containing nucleotides. Pediatrics. 1998; 101(2):242-9.

CARBOHYDRATES

Carbohydrates in breast milk include lactose and oligosaccharides as the main components, as well as glycoconjugates. As with most components of breast milk, oligosaccharides are found at high concentrations in colostrum (approximately 22 g/L), and are less abundant in mature milk (12 g/L).5656 Erney RM, Malone WT, Skelding MB, Marcon AA, Kleman-Leyer KM, O’Ryan ML, et al. Variability of human milk neutral oligosaccharides in a diverse population. J Pediatr Gastroenterol Nutr. 2000; 30(2):181-92. The types of oligosaccharides present in the milk also change during lactation and the concentration tends to decrease during breastfeeding.5757 Newburg DS. Are all human milks created equal? Variation in human milk oligosaccharides. J Pediatr Gastroenterol Nutr. 2000; 30(2):131-3.

The factor that promotes the growth of lactobacilli and bifidobacteria, which in turn inhibit the growth of pathogenic microorganisms by decreasing intestinal pH, was originally described as bifidus factor, but currently one of the substances identified as promoting this growth is N-acetyl-glucosamine.5858 Kleesen B, Bunke H, Tovar K, Noack J, Sawatzki G. Influence of two infant formulas and human milk on the development of the fecal flora in newborn infants. Acta Paediatr. 1995; 84(12):1347-56. Subsequently, various oligosaccharides with similar action have been identified, but it is possible that proteins in the milk also show this prebiotic activity.5959 Newburg DS. Do the binding properties of oligosaccharides in milk protect human infants from gastrointestinal bacteria? J Nutr. 1997; 127(5 Suppl): 980S-4S.

ANTIOXIDANT FACTORS

There are various antioxidants in human milk that can eliminate free radicals and thus limit the damage caused by oxidative stress. These compounds include α-tocopherol,6060 Romeu-Nadal M, Morera-Pons S, Castellote AI, López-Sabater MC. Determination of gamma- and alpha-tocopherols in human milk by a direct high performance liquid chromatographic method with UV-vis detection and comparison with evaporative light scattering detection. J Chromatogr A. 2006; 1114(1):132-7. β-carotene,6161 Sakurai T, Furukawa M, Asoh M, Kanno T, Kojima T, Yonekubo A. Fat-soluble and water-soluble vitamin contents of breast milk from Japanese women. J Nutr Sci Vitaminol (Tokyo). 2005; 51(4):239-47. cysteine,6262 Darragh AJ, Moughan PJ. The amino acid composition of human milk corrected for amino acid digestibility. Br J Nutr. 1998; 80(1):25-34. ascorbic acid,6161 Sakurai T, Furukawa M, Asoh M, Kanno T, Kojima T, Yonekubo A. Fat-soluble and water-soluble vitamin contents of breast milk from Japanese women. J Nutr Sci Vitaminol (Tokyo). 2005; 51(4):239-47. catalase, and glutathione peroxidase.6363 Friel JK, Martin SM, Langdon M, Herzberg GR, Buettner GR. Milk from mothers of both premature and full-term infants provides better antioxidant protection than does infant formula. Pediatr Res. 2002; 51(5):612-8.In vitro studies have demonstrated that breast milk degrades naturally-occurring hydrogen peroxide, as well as that produced by neutrophils, possibly due to their catalase content.6464 Grazioso CF, Buescher ES. Inhibition of neutrophil function by human milk. Cell Immunol. 1996; 168(2):125-32.

BREAST MILK CELLS

As they contain viable leukocytes, colostrum and breast milk differ from most other secretions. The concentration of these leukocytes is higher in colostrum and decreases during the first month of lactation, meaning that mature milk contains just 2% of the colostrum cell concentration, resulting in approximately 106 to 109 cells/mL in colostrum and 105 cells/mL in mature milk. Apart from epithelial cells, macrophages (32.6%) and neutrophils (45.1%) are present at a greater quantity in relation to lymphocytes (21.3%), the latter represented mainly by CD3+ T cells (83%), almost equally distributed between CD4+ and CD8+,6565 Barros MD, Carneiro-Sampaio MMS. Milk composition of low birth weight infant mothers. Acta Paediatr Scand. 1984; 73:693-5. as well as Tγδ+ cells (11%), CD16+ NK cells (3-4%), and B cells (2%).99 Lepage P, Van de Perre P. The immune system of breast milk: antimicrobial and anti-inflammatory properties. Adv Exp Med Biol. 2012; 743:121-37.

More recent studies suggest that the number of macrophages in breast milk has been overestimated, as only a small proportion of these cells contains the characteristic surface markers of macrophages, such as CD14.6666 Fan Y, Chong YS, Choolani MA, Cregan MD, Chan JK. Unravelling the mystery of stem/progenitor cells in human breast milk. PLoS One. 2010; 5(12):e14421. In fact, macrophages may only represent 15% of breast milk leukocytes. It has been demonstrated that SIgA has the capacity to opsonize particles and microorganisms, enhancing phagocytic and microbicide activities through increased superoxide anion production by the phagocytes in the colostrum.6767 Honorio-França AC, Isaac L, Trabulsi LR, Carneiro-Sampaio MMS. Colostral mononuclear phagocytes are able to kill enteropathogenic Escherichia coli (EPEC) opsonized by colostral IgA. Scand J Immunol. 1997; 46(1):59-66.

Breast milk T cells differ both in relative abundance and quality when compared to the T cells found in peripheral blood.6868 Sabbaj S, Ghosh MK, Edwards BH, Leeth R, Decker WD, Goepfert PA, et al. Breast milk-derived antigen-specific CD8+ T cells: An extra-lymphoid effector memory cell population in humans. J Immunol. 2005; 174(5):2951-6. The largest proportion of TCD8+ TCRgd+ (expressing L-selectin, integrin α4β7, MAdCAM-1) compared with the blood suggests that these cytotoxic T cells (CD8+) carry out selective homing from the mucosal immune system to the mammary gland.6868 Sabbaj S, Ghosh MK, Edwards BH, Leeth R, Decker WD, Goepfert PA, et al. Breast milk-derived antigen-specific CD8+ T cells: An extra-lymphoid effector memory cell population in humans. J Immunol. 2005; 174(5):2951-6.,6969 Wirt DP, Adkins LT, Palkowetz KH, Schmalstieg FC, Goldman AS. Activated and memory T lymphocytes in human milk. Cytometry. 1992; 13(3):282-90. CD4+ T cells in the breast milk are also present in an activated state and express CD45RO, a surface protein associated with immunological memory. More than 70% of the B cells in breast milk are CD27+IgD- switched memory cells primed to secrete antibodies with overrepresentation of large-sized B cells, plasmablasts, and plasma cells, which do not express the complement receptor.1212 Carlsson B, Hanson LA. Immunologic effects of breast-feeding on the infant. In: Ogra P, Lamm ME, Strober W, McGhee JR, Bienestock J, editors. Handbook of Mucosal Immunology. London: Academic Press; 1994. p.653-66.,7070 Tuaillon E, Valea D, Becquart P, Al Tabaa Y, Meda N, Bollore K, et al. Human milk-derived B cells: a highly activated switched memory cell population primed to secrete antibodies. J Immunol. 2009; 182(11):7155-62.

HUMAN MILK MICROBIOTA

More recently, several studies have shown that colostrum and breast milk are continuous sources of commensal and potentially probiotic bacteria for the infant’s intestine. This is an important finding given that intramammary breast milk has traditionally been considered sterile. In fact, human milk is a major source of bacteria for the intestine of infants, given that a baby that consumes approximately 800 mL/day of milk ingests approximately 1 × 105 and 1 × 107 bacteria per day.71 Several studies have shown that there is a transfer of bacterial strains through breastfeeding, at least for the genera Lactobacillus, Staphylococcus, Enterococcus, and Bifidobacterium,7272 Martín V, Maldonado-Barragán A, Moles L, Rodríguez-Baños M, Del Campo R, Fernández L, et al. Sharing of bacterial strains between breast milk and infant feces. J Hum Lact. 2012; 28(1):36-44. although recent techniques of microbial identification based on pyrosequencing of the 16S rDNA gene have enabled the identification of several other species (Table 2).7373 Fernández L, Langa S, Martín V, Maldonado A, Jiménez E, Martín R, et al. The human milk microbiota: origin and potential roles in health and disease. Pharmacol Res. 2013; 69(1):1-10.

It has been observed that the administration of strains of Lactobacillus from breast milk to 6-month old babies led to reductions of 46, 27 and 30% in the frequency of gastrointestinal, upper respiratory tract and total number of infections, respectively.7474 Maldonado J, Cañabate F, Sempere L, Vela F, Sánchez AR, Narbona E, et al. Human milk probiotic Lactobacillus fermentum CECT5716 reduces the incidence of gastrointestinal and upper respiratory tract infections in infants. J Pediatr Gastroenterol Nutr. 2012; 54(1):55-61.

Breast milk and protection against infections

Several epidemiological and experimental studies have been conducted to investigate the effect of human milk against different organisms involved in respiratory and gastrointestinal infections. These studies have demonstrated that human milk has antibodies against Shigella, Salmonella typhimurium, Campylobacter, Vibrio cholerae, Haemophilus influenzae, Streptococcus pneumoniae, Bordetella pertussis, respiratory syncytial virus, HIV, and other pathogens.77 Hanson LA, Korotkova M. The role of breastfeeding in prevention of neonatal infection. Semin Neonatol. 2002; 7(4):275-81.,7575 Quinello C, Quintilio W, Carneiro-Sampaio M, Palmeira P. Passive acquisition of protective antibodies reactive with Bordetella pertussis in newborns via placental transfer and breast-feeding. Scand J Immunol. 2010; 72(1):66-73.

Epidemiological data indicate that exclusively breastfed children are better protected against a variety of infections7676 Wright AL, Bauer M, Naylor A, Sutcliffe E, Clark L. Increasing breast-feeding rates to reduce infant illness at the community level. Pediatrics. 1998; 101(5):837-44. and apparently also against celiac disease in childhood7777 Ivarsson A, Hernell O, Stenlund H, Persson LA. Breast-feeding protects against celiac disease. Am J Clin Nutr. 2002; 75(5):914-21. as well as allergies and asthma,7878 Oddy WH, Holt PG, Sly PD, Read AW, Landau LI, Stanley FJ, et al. Association between breast-feeding and asthma in 6-year-old children: findings of a prospective birth cohort study. BMJ. 1999; 319(7213):815-9. although studies on the latter issue still show discrepant data.7979 Oddy WH, Peat JK, de Klerk NH. Maternal asthma, infant feeding, and the risk of asthma in childhood. J Allergy Clin Immunol. 2002; 110(1):65-7.,8080 Sears MR, Greene JM, Willan AR, Taylor DR, Flannery EM, Cowan JO, et al. Long-term relation between breast-feeding and development of atopy and asthma in children and young adults: a longitudinal study. Lancet. 2002; 360(9337):901-7. It is known that the risk of death from diarrhea can be reduced from 14 to 24 times in infants fed human milk, and that the frequency of diarrhea increases as the milk is replaced by other sources, until full weaning.8181 Kaiser AM. A warm chain for breast-feeding. Lancet. 1994; 344(8932):1239-41.

This effect is illustrated in a study conducted in Brazil showing that exclusive breastfeeding reduces the risk of death from diarrhea by 14.2 times, whereas partial breastfeeding is associated with a reduction of 4.2 times, both compared to the group that was not breastfed.8282 Victora CG, Smith PG, Vaughan JP, Nobre LC, Lombardi C, Teixeira AM, et al. Evidence for protection by breast-feeding against infant deaths from infectious diseases in Brazil. Lancet. 1987; 2(8554):319-22.

SIgA antibodies present in the colostrum and milk of Brazilian women have an important role in protecting against infections by enteropathogenic E. coli (EPEC). The first experiments demonstrated the strong capacity of colostrum (48 to 72 hours after delivery) and milk (from the 7th, 30th e 60th days of lactation) samples from mothers in the city of São Paulo to inhibit in vitro EPEC adherence to HEp-2 cells (Figure 2).8383 Carneiro-Sampaio MMS, Silva MLM, Carbonare SB, Palmeira P, Delneri MT, Honório AC, et al. Breast-feeding protection against enteropathogenic Escherichia coli. Rev Microbiol. 1996; 27:120-5. Next, it was demonstrated that SIgA was the primary mediator of bacterial inhibition, and that these antibodies alone, which are reactive with intimin, the main adhesin in EPEC, responsible for the binding of the bacteria to enterocytes, were able to strongly inhibit the adhesion of EPEC to the HEp-2 cells mentioned above. In turn, all samples of colostrum and milk from the mothers studied presented antibodies for intimin and other virulence factors of EPEC.1515 Carbonare SB, Silva ML, Palmeira P, Carneiro-Sampaio MM. Human colostrum IgA antibodies reacting to enteropathogenic Escherichia coli antigens and their persistence in the faeces of a breastfed infant. J Diarrhoeal Dis Res. 1997; 15(2):53-8.,8484 Adu-Bobie J, Trabulsi LR, Carneiro-Sampaio MMS, Dougan G, Frankel G. Identification of immunodominant region within the C-terminal cell binding domain of intimin alpha and beta from enteropathogenic Escherichia coli. Infect Immun. 1998; 66(12):5643-9.

85 Loureiro I, Frankel G, Adu-Bobie J, Dougan G, Trabulsi LR, Carneiro-Sampaio MMS. Human colostrum contains IgA antibodies reactive to enteropathogenic Escherichia coli virulence-associated proteins: Intimin, BfpA, EspA and EspB. J Pediatr Gastroenterol Nutr. 1998; 27(2):166-71.
-8686 Sanchez MI, Keller R, Hartland EL, Figueredo DMM, Batchelor M, Martinez MB, et al. Human colostrum and serum contain antibodies reactive to the intimin-binding region of the enteropathogenic Escherichia coli. J Pediatr Gastroenterol Nutr. 2000; 30(1):73-7. Similar data were found in samples of mothers of term newborns with low birth weight and premature babies.8787 Delneri MT, Carbonare SB, Palmeira P, Silva MLM, Carneiro-Sampaio MMS. Inhibition of enteropathogenic Escherichia coli to HEp-2 cells by colostrum and milk from mothers delivering low-birth-weight neonates. Eur J Pediatr. 1997; 156:493-8.

Figure 2
A. Photomicrograph of the appearance of the adherence of enteropathogenic E. coli (EPEC) on human epithelial cells in a culture of the HEp-2 cell lineage, where adhesion of bacteria can be observed in almost 100% of the cells in an adhesion pattern characteristic of EPEC called localized adherence, and (B) the inhibitory effect of the “pool” of human colostrum on EPEC adhesion to HEp-2 cells, where it can be noted that almost 100% of the HEp-2 cells are free of bacteria. 1,000 times magnification.

As a result of the concern for low birth weight newborns or premature infants, who often require banks of breast milk, the possibility of changing the biological properties of colostrum and milk was investigated after being subjected to the usual treatments of pasteurization, lyophilization, and exposure to microwaves.8888 Quan R, Yang C, Rubinstein S, Lewinston NJ, Sunshine P, Stevenson DK, et al. Effects of microwave radiation on anti-infective factors in human milk. Pediatrics. 1992; 89(4 Pt 1):667-9. These treatments did not alter the ability to inhibit bacterial adhesion, although pasteurization partially reduced the total IgA level and the level of anti-EPEC antibodies.8989 Carbonare SB, Palmeira P, Silva MLM, Carneiro-Sampaio MMS. Effect of microwave radiation, pasteurization and lyophilization on the ability of human milk to inhibit Escherichia coli adherence to HEp-2 cells. J Diarrhoeal Dis Res. 1996; 14(2):90-4. When neutralizing the virulence factors of EPEC, these antibodies protect the infant’s intestine against colonization and infection, and may also protect children against the systemic effects of LPS by inhibiting the absorption of the bacterial endotoxins involved in septic shock.9090 Nagao AT, Martinez CC, Takano OA, Vieira VS, Costa-Carvalho BT, Carneiro-Sampaio MMS. Placental transfer of IgG and IgG subclass antibodies anti-purified Escherichia coli LPS O16, O6 and O111. Scand J Immunol. 1998; 47(6):609-14.

In a study conducted with a sample of colostrum from one parturient woman with IgA deficiency, inhibitory activity was observed both for adhesion of EPEC and invasion of enteroinvasive E. coli (EIEC) in HEp-2 cells, at levels equivalent to normal control colostra. Furthermore, a high level of SIgM has been described in this secretion, which could represent a compensatory phenomenon to the SIgA deficiency.9191 Barros MD, Porto MHO, Leser PG, Grumach AS, Carneiro-Sampaio MMS. Study of colostrum of a patient with Selective IgA deficiency. Allergol Immunopathol (Madr). 1985; 13(4):331-4.

The inhibitory activity on the adhesion of shiga-like toxin-producing E. coli (STEC), enteroaggregative E. coli (EAggEC), enterotoxigenic E. coli (ETEC), and the invasion of EIEC has been further demonstrated in other studies.9292 Palmeira P, Carbonare SB, Amaral JA, De Franco MT, Carneiro-Sampaio MMS. Colostrum from healthy Brazilian women inhibits adhesion and contains IgA antibodies reactive with Shiga toxin-producing Escherichia coli. Eur J Pediatr. 2005; 164(1):37-43.

93 Fernandes RM, Carbonare SB, Carneiro-Sampaio MMS, Trabulsi LR. Inhibition of enteroaggregative Escherichia coli adhesion to HEp-2 cells by secretory immunoglobulin A from human colostrum. Pediatr Infect Dis J. 2001; 20(7):672-8.

94 Corrêa S, Palmeira P, Carneiro-Sampaio MMS, Nishimura LS, Guth BEC. Human colostrum contains IgA antibodies reactive to colonization factors I and II of enterotoxigenic Escherichia coli. FEMS Immunol Med Microbiol. 2006; 47(2):199-206.
-9595 Carbonare SB, Silva MLM, Trabulsi LR, Carneiro-Sampaio MMS. Inhibition of HEp-2 cell invasion by enteroinvasive Escherichia coli by human colostrum IgA. Int Arch Allergy Immunol. 1995; 108(2):113-8.

The role of breast milk in the protection against rotavirus infection is still unclear, as in some cases a delay is observed in the development of the disease, while in others the infections are asymptomatic.9696 Clemens J, Rao M, Ahmed F, Ward R, Huda S, Chakraborty J, et al. Breast-feeding and the risk of life-threatening rotavirus diarrhea: prevention or postponement?. Pediatrics. 1993; 92(5):680-5. However, a delay in the appearance of rotavirus in the feces has been reported when associated with high levels of SIgA antibodies in the milk.9797 Espinoza F, Paniagua M, Hallander H, Svensson L, Strannegård O. Rotavirus infections in young Nicaraguan children. Pediatr Infect Dis J. 1997; 16(6):564-71.

In relation to respiratory infections, studies investigating the protective ability of breast milk against otitis media have demonstrated effective protection against acute and prolonged infections.9898 Cushing AH, Samet JM, Lambert WE, Skipper BJ, Hunt WC, Young SA, et al. Breastfeeding reduces risk of respiratory illness in infants. Am J Epidemiol. 1998; 147(9):863-70.

99 Dewey KG, Heinig MJ, Nommsen-Rivers LA. Differences in morbidity between breast-fed and formula-fed infants. J Pediatr. 1995; 126(5 Pt 1):696-702.
-100100 Duncan B, Ey J, Holberg CJ, Wright AL, Martinez FD, Taussig LM. Exclusive breast-feeding for at least 4 months protects against otitis media. Pediatrics. 1993; 91(5):867-72. It is also suggested that breastfeeding may protect against upper respiratory tract infections, but this role still lacks confirmation.101101 Howie PW, Forsyth JS, Ogston SA, Clark A, Florey CD. Protective effect of breast feeding against infection. BMJ. 1990; 300(6716):11-6. A study conducted in the United States, comparing the effects of exclusive breastfeeding for 4 and 6 months on the appearance of pneumonia and otitis revealed a reduction of these infections in the group that was breastfed for 6 months compared to the group breastfed for 4 months.102102 Chantry CJ, Howard CR, Auinger P. Full breastfeeding duration and associated decrease in respiratory tract infection in US children. Pediatrics. 2006; 117(2):425-32.

Breast milk and protective effect on premature or underweight infants

Considering the importance of breastfeeding as an immune supplement for healthy term newborns, it is even more crucial in the case of prematurity. The main causes of morbidity, mortality, and sequelae in the long term in these children are sepsis, meningitis, and necrotizing enterocolitis (NEC), but there is evidence that breast milk oligosaccharides and antibodies can help protect against these diseases.3939 Lawrence RM, Pane CA. Human breast milk: current concepts of immunology and infectious diseases. Curr Probl Pediatr Adolesc Health Care. 2007; 37(1):7-36.,103103 Schnabl KL, Van Aerde JE, Thomson ABR, Clandinin MT. Necrotizing enterocolitis: a multifactorial disease with no cure. World J Gastroenterol. 2008; 14(14):2142-61.

One issue to be discussed is the daily amount of breast milk ingested and its effect on the incidence of infections. Two studies on premature newborns have addressed this issue. Furman et al. found that at least 50 mL/kg/day of human milk were needed to show a decrease in the rate of sepsis in very low birth weight infants,104104 Furman L, Taylor G, Minich N, Hack M. The effect of maternal milk on neonatal morbidity of very low-birth-weight infants. Arch Pediatr Adolesc Med. 2003; 157(1):66-71. while Schanler et al. demonstrated that children who received the same dose from birth to 90 days old or hospital discharge showed a reduction in both sepsis as well as NEC rates.105105 Schanler RJ, Lau C, Hurst NM, Smith EO. Randomized trial of donor human milk versus preterm formula as substitutes for mothers’ own milk in the feeding of extremely premature infants. Pediatrics. 2005; 116(2):400-6.

BREAST MILK AND LONG TERM PROTECTIVE EFFECT

There are many recent studies investigating a possible role of breastfeeding on the risk of developing many common diseases in which inflammation plays a central role in pathogenesis. There is a wide variety of milk components that affect the development and function of the immune system and that could exert this effect, as has already been demonstrated for allergic diseases, some showing protection, others not.106106 Saarinen UM, Kajosaari M. Breastfeeding as prophylaxis against atopic disease: prospective follow-up study until 17 years old. Lancet. 1995; 346(8982):1065-9.,107107 Van Asperen PP, Kemp AS, Mellis CM. Relationship of diet in the development of atopy in infancy. Clin Allergy. 1984; 14(6):525-32.

This protective effect in the long term can also be observed in epidemiological studies that suggest that human milk lowers the risk of development of autoimmune diseases such as type 1 and 2 diabetes mellitus, rheumatoid arthritis, celiac disease, ulcerative colitis, and Crohn’s disease.44 Hanson LA. Symposium on ‘Nutrition in early life: new horizons in a new century’. Session 1: Feeding and infant development. Breast-feeding and immune function. Proc Nutr Society. 2007; 66:384-96.

Some studies indicate that breastfeeding has a protective effect against chronic vascular diseases, including hypertension, obesity and/or insulin resistance.108108 Singhal A, Cole TJ, Fewtrell M, Lucas A. Breast milk feeding and lipoprotein profile in adolescents born preterm: follow-up of a prospective randomised study. Lancet. 2004; 363(9421):1571-8.

109 Singhal A, Lucas A. Early origins of cardiovascular disease: is there a unifying hypothesis? Lancet. 2004; 363(9421):1642-5.
-110110 Martin RM, Gunnell D, Smith GD. Breastfeeding in infancy and blood pressure in later life: systematic review and meta-analysis. Am J Epidemiol. 2005; 161(1):15-26. A meta-analysis has shown that breastfeeding protects against childhood tumors such as acute lymphoblastic leukemia, Hodgkin’s disease, and neuroblastoma.111111 Martin RM, Gunnell D, Owen CG, Smith GD. Breastfeeding and childhood cancer: a systematic review with meta-analysis. Int J Cancer. 2005; 117(6):1020-31.

CONCLUSION

Several clinical studies confirm the beneficial effects of breastfeeding on the growth, development, and anti-infective defense from infancy to adulthood. Breastfeeding not only provides an ideal nutritional composition for the newborn but also represents an extraordinary immunological integration between the mother and the infant. The expansion of knowledge about the immunological composition of breast milk reinforces the importance of many components present even in small amounts in this secretion, which is a perfect food and a supplement with increasingly recognized immunological value.

  • Study conducted at Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HC-FMUSP), São Paulo, SP, Brazil

REFERENCES

  • 1
    Lewis DB, Wilson CB. Developmental immunology and role of host defenses in neonatal susceptibility to infection. In: Remington JS, Klein JO, Wilson CB, Nizet V, Maldonado YA, editors. Infectious diseases of the fetus and newborn infant. 7.ed. Philadelphia: Saunders; 2011. p.83-169.
  • 2
    Hanson LA, Korotkova M, Lundin S, Håversen L, Silfverdal SA, Mattsby-Baltzer I, et al. The transfer of immunity from mother to child. Ann N Y Acad Sci. 2003; 987:199-206.
  • 3
    Hosea Blewett HJ, Cicalo MC, Holland CD, Field CJ. The immunological components of human milk. Adv Food Nutr Res. 2008; 54:45-80.
  • 4
    Hanson LA. Symposium on ‘Nutrition in early life: new horizons in a new century’. Session 1: Feeding and infant development. Breast-feeding and immune function. Proc Nutr Society. 2007; 66:384-96.
  • 5
    Morrow AL, Rangel JM. Human milk protection against infectious diarrhea: Implications for prevention and clinical care. Semin Pediatr Infect Dis. 2004; 15(4):221-8.
  • 6
    Hanson LA. Breastfeeding provides passive and likely long-lasting active immunity. Ann Allergy Asthma Immunol. 1998; 81(6):523-37.
  • 7
    Hanson LA, Korotkova M. The role of breastfeeding in prevention of neonatal infection. Semin Neonatol. 2002; 7(4):275-81.
  • 8
    Goldman AS, Thorpe LW, Goldblum RM, Hanson LA. Anti-inflammatory properties of human milk. Acta Paediatr Scand. 1986; 75(5):689-95.
  • 9
    Lepage P, Van de Perre P. The immune system of breast milk: antimicrobial and anti-inflammatory properties. Adv Exp Med Biol. 2012; 743:121-37.
  • 10
    Brandtzaeg P. The mucosal immune system and its integration with the mammary glands. J Pediatr. 2010; 156(2 Suppl):S8-15.
  • 11
    Brandtzaeg P, Kiyono H, Pabst R, Russell MW. Terminology: nomenclature of mucosa-associated lymphoid tissue. Mucosal Immunol. 2008; 1(1):31-7.
  • 12
    Carlsson B, Hanson LA. Immunologic effects of breast-feeding on the infant. In: Ogra P, Lamm ME, Strober W, McGhee JR, Bienestock J, editors. Handbook of Mucosal Immunology. London: Academic Press; 1994. p.653-66.
  • 13
    Johansen FE, Brandtzaeg P. Transcriptional regulation of the mucosal IgA system. Trends Immunol. 2004; 25(3):150-7.
  • 14
    Palmeira P, Costa-Carvalho BT, Arslanian C, Pontes GN, Nagao AT, Carneiro-Sampaio MM. Transfer of antibodies across the placenta and in breast milk from mothers on intravenous immunoglobulin. Pediatr Allergy Immunol. 2009; 20(6):528-35.
  • 15
    Carbonare SB, Silva ML, Palmeira P, Carneiro-Sampaio MM. Human colostrum IgA antibodies reacting to enteropathogenic Escherichia coli antigens and their persistence in the faeces of a breastfed infant. J Diarrhoeal Dis Res. 1997; 15(2):53-8.
  • 16
    de Araújo AN, Giugliano LG. Lactoferrin and free secretory component of human milk inhibit the adhesion of enteropathogenic Escherichia coli to HeLa cells. BMC Microbiol. 2001; 1:25.
  • 17
    Bessler HC, de Oliveira IR, Giugliano LG. Human milk glycoproteins inhibit the adherence of Salmonella typhimurium to HeLa cells. Microbiol Immunol. 2006; 50(11):877-82.
  • 18
    Hammerschmidt S, Talay SR, Brandtzaeg P, Chhatwal GS. SpsA, a novel pneumococcal surface protein with specific binding to secretory immunoglobulin A and secretory component. Mol Microbiol. 1997; 25(6):1113-24.
  • 19
    Dallas SD, Rolfe RD. Binding of Clostridium difficile toxin A to human milk secretory component. J Med Microbiol. 1998; 47(10):879-88.
  • 20
    Chipman DM, Sharon N. Mechanism of lysozyme action. Science. 1969; 165(3892):454-65.
  • 21
    Ellison RTJ, Giehl TJ. Killing of Gram-negative bacteria by lactoferrin and lysozyme. J Clin Invest. 1991; 88(4):1080-91.
  • 22
    Lee-Huang S, Huang PL, Sun Y, Huang PL, Kung HF, Blithe DL, et al. Lysozyme and RNases as anti-HIV components in beta-core preparations of human chorionic gonadotropin. Proc Natl Acad Sci U S A. 1999; 96(6):2678-81.
  • 23
    Houghton M, Santoso H, Soetjiningsih, Gracey M. Lactoferrin concentrations in the breast milk of Indonesian mothers. Paediatr Indones. 1985; 25(9-10):163-6.
  • 24
    Mattsby-Baltzer I, Roseanu A, Motas C, Elverfors J, Engberg I, Hanson LA. Lactoferrin or a fragment thereof inhibits the endotoxin-induced interleukin-6 response in human monocytic cells. Pediatr Res. 1996; 40(2):257-62.
  • 25
    Elass E, Masson M, Mazurier J, Legrand D. Lactoferrin inhibits the lipopolysaccharide-induced expression and proteoglycan-binding ability of interleukin-8 in human endothelial cells. Infect Immun. 2002; 70(4):1860-6.
  • 26
    Håversen LA, Baltzer L, Dolphin G, Hanson LA, Mattsby-Baltzer I. Anti-inflammatory activities of human lactoferrin in acute dextran sulphate-induced colitis in mice. Scand J Immunol. 2003; 57(1):2-10.
  • 27
    Hashizume S, Kuroda K, Murakami H. Identification of lactoferrin as an essential growth factor for human lymphocytic cell lines in serum-free medium. Biochim Biophys Acta. 1983; 763(4):377-82.
  • 28
    Tomita M, Bellamy W, Takase M, Yamauchi K, Wakabayashi H, Kawase K. Potent antibacterial peptides generated by pepsin digestion of bovine lactoferrin. J Dairy Sci. 1991; 74(12):4137-42.
  • 29
    Steele WF, Morrison M. Antistreptococcal activity of lactoperoxidase. J Bacteriol. 1969; 97(2):635-9.
  • 30
    Björck L, Rosén CG, Marshall V, Reiter B. Antibacterial activity of lactoperoxidase system in milk against pseudomonas and other Gram-negative bacteria. Appl Microbiol. 1975; 30(2):199-204.
  • 31
    Lönnerdal B. Nutritional and physiologic significance of human milk proteins. Am J Clin Nutr. 2003; 77(6):1537S-43S.
  • 32
    Pellegrini A, Thomas U, Bramaz N, Hunziker P, von Fellenberg R. Isolation and identification of three bactericidal domains in the bovine alpha-lactalbumin molecule. Biochim Biophys Acta. 1999; 1426(3):439-48.
  • 33
    Hallgren O, Aits S, Brest P, Gustafsson L, Mossberg AK, Wullt B, et al. Apoptosis and tumor cell death in response to HAMLET (human alpha-lactalbumin made lethal to tumor cells). Adv Exp Med Biol. 2008; 606:217-40.
  • 34
    Adkins Y, Lönnerdal B. Potential host-defense role of a human milk vitamin B-12-binding protein, haptocorrin, in the gastrointestinal tract of breastfed infants, as assessed with porcine haptocorrin in vitro. Am J Clin Nutr. 2003; 77(5):1234-40.
  • 35
    Vidal K, van den Broek P, Lorget F, Donnet-Hughes A. Osteoprotegerin in human milk: A potential role in the regulation of bone metabolism and immune development. Pediatr Res. 2004; 55(6):1001-8.
  • 36
    Vidal K, Serrant P, Schlosser B, van den Broek P, Lorget F, Donnet-Hughes A. Osteoprotegerin production by human intestinal epithelial cells: a potential regulator of mucosal immune responses. Am J Physiol Gastrointest Liver Physiol. 2004; 287(4):G836-G44.
  • 37
    Blewett HJH, Cicalo MC, Holland CD, Field CJ. The immunological components of human milk. Adv Food Nutr. 2008; 54:45-80.
  • 38
    Labéta MO, Vidal K, Nores JE, Arias M, Vita N, Morgan BP, et al. Innate recognition of bacteria in human milk is mediated by a milk-derived highly expressed pattern recognition receptor, soluble CD14. J Exp Med. 2000; 191(10):1807-12.
  • 39
    Lawrence RM, Pane CA. Human breast milk: current concepts of immunology and infectious diseases. Curr Probl Pediatr Adolesc Health Care. 2007; 37(1):7-36.
  • 40
    Skansén-Saphir U, Lindfors A, Andersson U. Cytokine production in mononuclear cells of human milk studied at the single cell level. Pediatr Res. 1993; 34(2):213-6.
  • 41
    Hara T, Irie K, Saito S, Ichijo M, Yamada M, Yanai N, et al. Identification of macrophage colony-stimulating factor in human milk and mammary epithelial cells. Pediatr Res. 1995(4 Pt 1); 37:437-43.
  • 42
    Gilmore WS, McKelvey-Martin VJ, Rutherford S, Strain JJ, Loane P, Kell M, et al. Human milk contains granulocyte colony stimulating factor. Eur J Clin Nutr. 1994; 48(3):222-4.
  • 43
    Garofalo R. Cytokines in human milk. J Pediatr. 2010; 156(2 Suppl):S36-40.
  • 44
    Basolo F, Fiore L, Fontanini G, Giulio P, Simonetta C, Falcone V, et al. Expression of response to interleukin 6 (IL6) in human mammary tumors. Cancer Res. 1996; 56(13):3118-22.
  • 45
    Verhasselt V. Neonatal tolerance under breastfeeding influence: the presence of allergen and transforming growth factor-b in breast milk protects the progeny from allergic asthma. J Pediatr. 2010; 156(2 Suppl):S16-20.
  • 46
    Keeney SE, Schmalstieg FC, Palkowetz KH, Rudloff E, Le BM, Goldman AS. Activated neutrophils and neutrophil activators in human milk: increased expression of CD11b and decreased expression of L-selectin. J Leukoc Biol. 1993; 54(2):97-104.
  • 47
    Ebert E. IL-8, RANTES, and GRO are chemotactic for intraepithelial lymphocytes (IEL). Gastroenterology. 1995; 108(4):A813.
  • 48
    Cocchi F, DeVico AL, Garzino-Demo A, Arya SK, Gallo RC, Lusso P. Identification of RANTES, MIP-1 alpha, and MIP-1 beta as the major HIV suppressive factors produced by CD8+ T cells. Science. 1995; 270(5243):1811-5.
  • 49
    German JB, Dillard CJ. Composition, structure and absorption of milk lipids: a source of energy, fat-soluble nutrients and bioactive molecules. Crit Rev Food Sci Nutr. 2006; 46(1):57-92.
  • 50
    Isaacs CE. The antimicrobial function of milk lipids. Adv Nutr Res. 2001; 10:271-85.
  • 51
    Thormar H, Isaacs CE, Brown HR, Barshatzky MR, Pessolano T. Inactivation of enveloped viruses and killing of cells by fatty acids and monoglycerides. Antimicrob Agents Chemother. 1987; 31(1):27-31.
  • 52
    Welsh JK, Skurrie IJ, May JT. Use of Semliki forest virus to identify lipid-mediated antiviral activity and anti-alphavirus immunoglobulin A in human milk. Infect Immun. 1978; 19(2):395-401.
  • 53
    Schroten H, Hanisch FG, Plogmann R, Hacker J, Uhlenbruck G, Nobis-Bosch R, et al. Inhibition of adhesion of S-fimbriated Escherichia coli to buccal epithelial cells by human milk fat globule membrane components: a novel aspect of the protective function of mucins in the nonimmunoglobulin fraction. Infect Immun. 1992; 60(7):2893-9.
  • 54
    Kvistgaard AL, Pallesen LT, Arias CF, López S, Petersen TE, Heegaard CW, et al. Inhibitory effects of human and bovine milk constituents on rotavirus infections. J Dairy Sci. 2004; 87(12):4088-96.
  • 55
    Pickering LK, Granoff DM, Erickson JR, Masor ML, Cordle CT, Schaller JP, et al. Modulation of the immune system by human milk and infant formula containing nucleotides. Pediatrics. 1998; 101(2):242-9.
  • 56
    Erney RM, Malone WT, Skelding MB, Marcon AA, Kleman-Leyer KM, O’Ryan ML, et al. Variability of human milk neutral oligosaccharides in a diverse population. J Pediatr Gastroenterol Nutr. 2000; 30(2):181-92.
  • 57
    Newburg DS. Are all human milks created equal? Variation in human milk oligosaccharides. J Pediatr Gastroenterol Nutr. 2000; 30(2):131-3.
  • 58
    Kleesen B, Bunke H, Tovar K, Noack J, Sawatzki G. Influence of two infant formulas and human milk on the development of the fecal flora in newborn infants. Acta Paediatr. 1995; 84(12):1347-56.
  • 59
    Newburg DS. Do the binding properties of oligosaccharides in milk protect human infants from gastrointestinal bacteria? J Nutr. 1997; 127(5 Suppl): 980S-4S.
  • 60
    Romeu-Nadal M, Morera-Pons S, Castellote AI, López-Sabater MC. Determination of gamma- and alpha-tocopherols in human milk by a direct high performance liquid chromatographic method with UV-vis detection and comparison with evaporative light scattering detection. J Chromatogr A. 2006; 1114(1):132-7.
  • 61
    Sakurai T, Furukawa M, Asoh M, Kanno T, Kojima T, Yonekubo A. Fat-soluble and water-soluble vitamin contents of breast milk from Japanese women. J Nutr Sci Vitaminol (Tokyo). 2005; 51(4):239-47.
  • 62
    Darragh AJ, Moughan PJ. The amino acid composition of human milk corrected for amino acid digestibility. Br J Nutr. 1998; 80(1):25-34.
  • 63
    Friel JK, Martin SM, Langdon M, Herzberg GR, Buettner GR. Milk from mothers of both premature and full-term infants provides better antioxidant protection than does infant formula. Pediatr Res. 2002; 51(5):612-8.
  • 64
    Grazioso CF, Buescher ES. Inhibition of neutrophil function by human milk. Cell Immunol. 1996; 168(2):125-32.
  • 65
    Barros MD, Carneiro-Sampaio MMS. Milk composition of low birth weight infant mothers. Acta Paediatr Scand. 1984; 73:693-5.
  • 66
    Fan Y, Chong YS, Choolani MA, Cregan MD, Chan JK. Unravelling the mystery of stem/progenitor cells in human breast milk. PLoS One. 2010; 5(12):e14421.
  • 67
    Honorio-França AC, Isaac L, Trabulsi LR, Carneiro-Sampaio MMS. Colostral mononuclear phagocytes are able to kill enteropathogenic Escherichia coli (EPEC) opsonized by colostral IgA. Scand J Immunol. 1997; 46(1):59-66.
  • 68
    Sabbaj S, Ghosh MK, Edwards BH, Leeth R, Decker WD, Goepfert PA, et al. Breast milk-derived antigen-specific CD8+ T cells: An extra-lymphoid effector memory cell population in humans. J Immunol. 2005; 174(5):2951-6.
  • 69
    Wirt DP, Adkins LT, Palkowetz KH, Schmalstieg FC, Goldman AS. Activated and memory T lymphocytes in human milk. Cytometry. 1992; 13(3):282-90.
  • 70
    Tuaillon E, Valea D, Becquart P, Al Tabaa Y, Meda N, Bollore K, et al. Human milk-derived B cells: a highly activated switched memory cell population primed to secrete antibodies. J Immunol. 2009; 182(11):7155-62.
  • 71
    Heikkilä MP, Saris PEJ. Inhibition of Staphylococcus aureus by the commensal bacteria of human milk. J Appl Microbiol. 2003; 95(3):471-8.
  • 72
    Martín V, Maldonado-Barragán A, Moles L, Rodríguez-Baños M, Del Campo R, Fernández L, et al. Sharing of bacterial strains between breast milk and infant feces. J Hum Lact. 2012; 28(1):36-44.
  • 73
    Fernández L, Langa S, Martín V, Maldonado A, Jiménez E, Martín R, et al. The human milk microbiota: origin and potential roles in health and disease. Pharmacol Res. 2013; 69(1):1-10.
  • 74
    Maldonado J, Cañabate F, Sempere L, Vela F, Sánchez AR, Narbona E, et al. Human milk probiotic Lactobacillus fermentum CECT5716 reduces the incidence of gastrointestinal and upper respiratory tract infections in infants. J Pediatr Gastroenterol Nutr. 2012; 54(1):55-61.
  • 75
    Quinello C, Quintilio W, Carneiro-Sampaio M, Palmeira P. Passive acquisition of protective antibodies reactive with Bordetella pertussis in newborns via placental transfer and breast-feeding. Scand J Immunol. 2010; 72(1):66-73.
  • 76
    Wright AL, Bauer M, Naylor A, Sutcliffe E, Clark L. Increasing breast-feeding rates to reduce infant illness at the community level. Pediatrics. 1998; 101(5):837-44.
  • 77
    Ivarsson A, Hernell O, Stenlund H, Persson LA. Breast-feeding protects against celiac disease. Am J Clin Nutr. 2002; 75(5):914-21.
  • 78
    Oddy WH, Holt PG, Sly PD, Read AW, Landau LI, Stanley FJ, et al. Association between breast-feeding and asthma in 6-year-old children: findings of a prospective birth cohort study. BMJ. 1999; 319(7213):815-9.
  • 79
    Oddy WH, Peat JK, de Klerk NH. Maternal asthma, infant feeding, and the risk of asthma in childhood. J Allergy Clin Immunol. 2002; 110(1):65-7.
  • 80
    Sears MR, Greene JM, Willan AR, Taylor DR, Flannery EM, Cowan JO, et al. Long-term relation between breast-feeding and development of atopy and asthma in children and young adults: a longitudinal study. Lancet. 2002; 360(9337):901-7.
  • 81
    Kaiser AM. A warm chain for breast-feeding. Lancet. 1994; 344(8932):1239-41.
  • 82
    Victora CG, Smith PG, Vaughan JP, Nobre LC, Lombardi C, Teixeira AM, et al. Evidence for protection by breast-feeding against infant deaths from infectious diseases in Brazil. Lancet. 1987; 2(8554):319-22.
  • 83
    Carneiro-Sampaio MMS, Silva MLM, Carbonare SB, Palmeira P, Delneri MT, Honório AC, et al. Breast-feeding protection against enteropathogenic Escherichia coli. Rev Microbiol. 1996; 27:120-5.
  • 84
    Adu-Bobie J, Trabulsi LR, Carneiro-Sampaio MMS, Dougan G, Frankel G. Identification of immunodominant region within the C-terminal cell binding domain of intimin alpha and beta from enteropathogenic Escherichia coli. Infect Immun. 1998; 66(12):5643-9.
  • 85
    Loureiro I, Frankel G, Adu-Bobie J, Dougan G, Trabulsi LR, Carneiro-Sampaio MMS. Human colostrum contains IgA antibodies reactive to enteropathogenic Escherichia coli virulence-associated proteins: Intimin, BfpA, EspA and EspB. J Pediatr Gastroenterol Nutr. 1998; 27(2):166-71.
  • 86
    Sanchez MI, Keller R, Hartland EL, Figueredo DMM, Batchelor M, Martinez MB, et al. Human colostrum and serum contain antibodies reactive to the intimin-binding region of the enteropathogenic Escherichia coli. J Pediatr Gastroenterol Nutr. 2000; 30(1):73-7.
  • 87
    Delneri MT, Carbonare SB, Palmeira P, Silva MLM, Carneiro-Sampaio MMS. Inhibition of enteropathogenic Escherichia coli to HEp-2 cells by colostrum and milk from mothers delivering low-birth-weight neonates. Eur J Pediatr. 1997; 156:493-8.
  • 88
    Quan R, Yang C, Rubinstein S, Lewinston NJ, Sunshine P, Stevenson DK, et al. Effects of microwave radiation on anti-infective factors in human milk. Pediatrics. 1992; 89(4 Pt 1):667-9.
  • 89
    Carbonare SB, Palmeira P, Silva MLM, Carneiro-Sampaio MMS. Effect of microwave radiation, pasteurization and lyophilization on the ability of human milk to inhibit Escherichia coli adherence to HEp-2 cells. J Diarrhoeal Dis Res. 1996; 14(2):90-4.
  • 90
    Nagao AT, Martinez CC, Takano OA, Vieira VS, Costa-Carvalho BT, Carneiro-Sampaio MMS. Placental transfer of IgG and IgG subclass antibodies anti-purified Escherichia coli LPS O16, O6 and O111. Scand J Immunol. 1998; 47(6):609-14.
  • 91
    Barros MD, Porto MHO, Leser PG, Grumach AS, Carneiro-Sampaio MMS. Study of colostrum of a patient with Selective IgA deficiency. Allergol Immunopathol (Madr). 1985; 13(4):331-4.
  • 92
    Palmeira P, Carbonare SB, Amaral JA, De Franco MT, Carneiro-Sampaio MMS. Colostrum from healthy Brazilian women inhibits adhesion and contains IgA antibodies reactive with Shiga toxin-producing Escherichia coli. Eur J Pediatr. 2005; 164(1):37-43.
  • 93
    Fernandes RM, Carbonare SB, Carneiro-Sampaio MMS, Trabulsi LR. Inhibition of enteroaggregative Escherichia coli adhesion to HEp-2 cells by secretory immunoglobulin A from human colostrum. Pediatr Infect Dis J. 2001; 20(7):672-8.
  • 94
    Corrêa S, Palmeira P, Carneiro-Sampaio MMS, Nishimura LS, Guth BEC. Human colostrum contains IgA antibodies reactive to colonization factors I and II of enterotoxigenic Escherichia coli. FEMS Immunol Med Microbiol. 2006; 47(2):199-206.
  • 95
    Carbonare SB, Silva MLM, Trabulsi LR, Carneiro-Sampaio MMS. Inhibition of HEp-2 cell invasion by enteroinvasive Escherichia coli by human colostrum IgA. Int Arch Allergy Immunol. 1995; 108(2):113-8.
  • 96
    Clemens J, Rao M, Ahmed F, Ward R, Huda S, Chakraborty J, et al. Breast-feeding and the risk of life-threatening rotavirus diarrhea: prevention or postponement?. Pediatrics. 1993; 92(5):680-5.
  • 97
    Espinoza F, Paniagua M, Hallander H, Svensson L, Strannegård O. Rotavirus infections in young Nicaraguan children. Pediatr Infect Dis J. 1997; 16(6):564-71.
  • 98
    Cushing AH, Samet JM, Lambert WE, Skipper BJ, Hunt WC, Young SA, et al. Breastfeeding reduces risk of respiratory illness in infants. Am J Epidemiol. 1998; 147(9):863-70.
  • 99
    Dewey KG, Heinig MJ, Nommsen-Rivers LA. Differences in morbidity between breast-fed and formula-fed infants. J Pediatr. 1995; 126(5 Pt 1):696-702.
  • 100
    Duncan B, Ey J, Holberg CJ, Wright AL, Martinez FD, Taussig LM. Exclusive breast-feeding for at least 4 months protects against otitis media. Pediatrics. 1993; 91(5):867-72.
  • 101
    Howie PW, Forsyth JS, Ogston SA, Clark A, Florey CD. Protective effect of breast feeding against infection. BMJ. 1990; 300(6716):11-6.
  • 102
    Chantry CJ, Howard CR, Auinger P. Full breastfeeding duration and associated decrease in respiratory tract infection in US children. Pediatrics. 2006; 117(2):425-32.
  • 103
    Schnabl KL, Van Aerde JE, Thomson ABR, Clandinin MT. Necrotizing enterocolitis: a multifactorial disease with no cure. World J Gastroenterol. 2008; 14(14):2142-61.
  • 104
    Furman L, Taylor G, Minich N, Hack M. The effect of maternal milk on neonatal morbidity of very low-birth-weight infants. Arch Pediatr Adolesc Med. 2003; 157(1):66-71.
  • 105
    Schanler RJ, Lau C, Hurst NM, Smith EO. Randomized trial of donor human milk versus preterm formula as substitutes for mothers’ own milk in the feeding of extremely premature infants. Pediatrics. 2005; 116(2):400-6.
  • 106
    Saarinen UM, Kajosaari M. Breastfeeding as prophylaxis against atopic disease: prospective follow-up study until 17 years old. Lancet. 1995; 346(8982):1065-9.
  • 107
    Van Asperen PP, Kemp AS, Mellis CM. Relationship of diet in the development of atopy in infancy. Clin Allergy. 1984; 14(6):525-32.
  • 108
    Singhal A, Cole TJ, Fewtrell M, Lucas A. Breast milk feeding and lipoprotein profile in adolescents born preterm: follow-up of a prospective randomised study. Lancet. 2004; 363(9421):1571-8.
  • 109
    Singhal A, Lucas A. Early origins of cardiovascular disease: is there a unifying hypothesis? Lancet. 2004; 363(9421):1642-5.
  • 110
    Martin RM, Gunnell D, Smith GD. Breastfeeding in infancy and blood pressure in later life: systematic review and meta-analysis. Am J Epidemiol. 2005; 161(1):15-26.
  • 111
    Martin RM, Gunnell D, Owen CG, Smith GD. Breastfeeding and childhood cancer: a systematic review with meta-analysis. Int J Cancer. 2005; 117(6):1020-31.

Publication Dates

  • Publication in this collection
    Sept 2016

History

  • Received
    29 June 2016
  • Accepted
    26 July 2016
Associação Médica Brasileira R. São Carlos do Pinhal, 324, 01333-903 São Paulo SP - Brazil, Tel: +55 11 3178-6800, Fax: +55 11 3178-6816 - São Paulo - SP - Brazil
E-mail: ramb@amb.org.br