6 : THE NEXT BEST THING

"Perhaps the most convincing statement in favour of breast-feeding is that Nature intended it. We believe ourselves to be the products of evolution over eons of time, and anyone who proposes to improve on the evolutionary process lacks humility and must be a fool."

--DR. JOHN DOBBING

Human breast milk was for a long time the only nutrition available to infants and when mothers could not feed, the only alternative was to make arrangements for wet nurses. The thought of giving calf's food to a human infant was inconceivable centuries ago. However, during the 18th century, with a shortage of wet nurses and the evolution of elite social classes where breast-feeding interfered with social activities, substitute milk, first from the ass and goat, and then from cow, became popular.

Today, in the West, breast-feeding is not a choive method of feeding for various practical, social, cultural, economic and commercial reasons. Milk substitutes contribute substantially to infant nutrition today. The choice of milk substitutes is wide, ranging from unprocessed milks from other mammalian species to totally synthetic formulas based on petroleum hydrocarbons. A plausible substitute to breast milk, regardless of its nature and source, should meet the following criteria:

. high in nutritional value;

. low allergenicity;

. simple to prepare and store;

. acceptable odor/taste;

. reasonable cost.

Cow`s milk was the first commercially successful substitute for human milk. Cow's milk was later substituted with formulas which have come a long way in imitating human milk. It will, however, never be able to duplicate human milk, for one simple reason: we still do not know what makes human milk so good for humans. Therefore, comparing these products on the basis of their composition alone is not fair since each of the milk substitutes fulfils one or the other need of the infant better but no substitute fulfils all the needs as well as does human milk.We will examine here the various milk substitutes:Pooled Human MilkThe most suitable nourishment for all healthy, mature, newborn infants is their own mother`s milk. However, there is controversy over what constitutes ideal nutrition for low-birth-weight, pre-term and sick newborns if the mother and child separate after delivery, as happens most often in these instances. These situations and others where the mother`s milk is not readily available, seem best resolved with milk from a human milk bank.

However, some medical scientist argue with this position. They believe that pooled human milk does not supply the nutritional requirement of pre-term infants since each infant has different requirements. This had led to a new science, "lactoengineering," wherein specific needs of the infant are calculated and provided for, based on various mathematical formulas.

For healthy infants born at term, the pooled human milk is the best alternative, even though some characteristics of milk change in the processing of pooled milk.

Milk for the banks comes from lactating mothers either from drippings, expressing the breast by hand, or by pumping. Expressed milk is higher in fat concentration than the dripping milk with the concentration ranging from 1.5 percent to 3.5 percent. Even so, it is lower in fat than infant formulas.

The collected milk is pooled to dilute the effects of any allergy-causing proteins, fat and other composition differences. It is then pasteurized and sterilized before being given to babies. Allergenicity of milk can be further reduced by heating it before serving which applies to formula milk as well.

Human milk banking is a complicated process which includes freezing, thawing, pasteurization, skim and cream fractionation, lyophilization, fortification, and reconstitution. It is uncertain whether these steps destroy important growth and immune factors and vitamins. Future scientific studies should address this issue. Storage conditions and heating or freezing of pooled milk also cause a loss in its antiinfective properties.

The risks in using pooled human milk are somewhat similar to using pooled blood. Infections may spread through pooled milk if not checked in the processing. There is no scientific evidence that AIDS can be transferred through milk banks. AIDS viruses would likely not survive the processing steps in milk banking. Recently, however, a disturbing statement was made in the April 1987 Report of Surgeon General's Workshop on Children with HIV [AIDS] Infections and their Families. Dr. Martha Rogers, formerly a staff member of AIDS research at Center for Disease Control, states in this report:

Evidence suggests that perinatal transmission can occur by three modes:

1) transplacental passage of the virus in utero,

2)exposure to infected maternal blood and vaginal fluids during the labor and delivery of the infant, and

3)post partum ingestion of breast milk containing the virus.

The proportion of perinatally acquired cases attributable to each of these modes is unknown.

In the same report, Dr. Rogers writes:

..transmission through close but nonsexual contact (so called 'casual') has been extremely rare. Only three possible cases have been reported. Two of these cases involved nursing care of bedridden patients associated with extensive and repeated contact with blood and body fluids of the infected patient. The other case involved apparent transmission between two siblings, but the nature of the contact was not well characterized. None of the family members of the over 30,000 AIDS cases reported to the Center for Disease Control has developed AIDS as a result of household contact.The scare of AIDS virus spreading through breast-feeding and human milk has put a damper on human milk banks. Two such banks recently closed in Chicago. Those still operating are facing financial hardships. No agency of the federal government is taking any interest in resolving this issue.There is a dire need to support the few remaining milk banks in this country (appendix 6.1). There is a need to start more milk banks, an activity which should be of economic interest to small community hospitals, so badly stung in these tough times of DRG regulations.

The advantages for the new mothers in donating milk go beyond providing nutrition for the needy. Many mothers will find that pumping extra milk would:

.improve quality of milk for their own child;

.help return uterus back to normal faster;

.reduce risk of infections and breast cancer;

.reduce emotional stress;

.delay ovulation;

.help lose excess body fat fast;

.improve their sex life;

.give them emotional satisfaction from sharing.

It should be highly rewarding to the contributors of the milk bank to know that the most valuable nutrition, which only they can produce, is not wasted. It can even be financially rewarding. There is no better philanthropic activity for the new mothers to engage in than to contribute to a milk bank. It is a noble and righteous cause.

Other Mammalian MilksThe choice of goat, yak, reindeer or other milks depends largely on their regional availability. The advantages and disadvantages of these alternatives were discussed in chapter 4.

Cow's milk started at the pre-weaning stage continues to provide toddlers and pre-school children with important nutrients. For example, a half-quart of milk provides a two-year-old with just about 100 percent of the calcium and riboflavin, 50 percent of the protein and 25 percent of the daily energy requirements. Older children have a lesser need to rely on cow's milk for their nutrition. The need to stop using cow's milk arises when individuals:

. are intolerant to cow`s milk proteins;

. have multiple food allergies;

. develop diarrhea when using cow`s milk;

. are lactose intolerant;

. have galactosemia or other errors of metabolism;

. are vegetarians.Cow's milk is sold in different forms, many modified to meet specific taste and nutritional requirements:

Grade A Whole Milk: Whole milk containing not less than 3.25 percent fat and not less than 8.25 percent non-fat milk solids.

Low Fat Milk: Milk: containing two percent or one percent fat.

Skim Milk: Milk with less than 0.5 percent milk fat with added vitamin D to replace the vitamin lost during fat removal.

Powdered Milk: Whole or skim, has water removed, costs only about one-third of the regular milk and has the same nutritional values and problems as milk. The taste of reconstituted, powdered milk is improved by letting it sit for 24 hours in refrigerator. The small sacrifice in taste is worth the cost savings.

Evaporated Milk: Fresh milk less sixty percent of the water. All other properties remain the same except itis often less allergic.

Condensed Milk: Evaporated milk to which sugar is added.

Filled milk: Milk to which fat is added, such as from vegetable sources along with color or flavor. It has the consistency of evaporated milk, is cheaper and has less cholesterol than whole milk. The history of filled milk is very interesting. About 60 years ago the U.S. Congress enacted legislation prohibiting the interstate transportation of filled milk in response to the dairy industry protest. Charles Hauser and his Milnot Company who were distributing filled milk, despite theprohibition, sued the government, failed in their attempt to overturn the legislation and Hauser went to jail for a weekend before being pardoned by President Franklin Roosevelt. In 1973 the federal courts ruled that the Filled Milk Act was unconstitutional. The Food and Drug Administration declared that filled milk is safe, wholesome, and proper for human nutrition and Charles Hauser was vindicated after 50 years. Filled milk is now legal.

Yogurt: Fermented milk which has long been popular in the Middle East and has recently become a fad in the West as a nutritive alternate to milk. It has less fat and little allergy-causing lactose. If anything among the dairy products comes close to being a perfect food, it is yogurt.

Buttermilk: Old-fashioned buttermilk is the liquid remaining after butter is churned. Commercial buttermilk comes from pasteurized skim or partially skim milk that is cultured with bacteria to make it thicker and more tart. Salt is added to retard spoilage and improve flavor.

Acidophilus Milk: Usually made from skim or low-fat milk, this is milk cultured with acidophilus bacteria added after pasteurization or heating. for easier digestion. It has same nutritive value as whole milk but is better tolerated digestively.

Sweet Creams: All creams are pasteurized and are at least 18 percent milk fat. Light cream has 18 to 30 percent fat; heavy cream has at least 36 percent milk fat; and half-and-half is at least 10.5 to 18 percent milk fat.

Sour Cream: Light cream cultured with bacteria, to which is added nonfat dry milk, enzymes, or chemical additives. Sour cream contains at least 18 percent milk fat.

Butter: Made from milk or cream or a mixture of both, butter contains at least 80 percent milk fat. Salt andcoloring are added. Salted butter may be made from either sweet or soured cream.

Ghee: Used primarily in northern India, ghee is clarified butter prepared by heating and coagulating milk solids. It is mostly milk fat.

Cheese: Cheese comes from heating milk with an enzyme, renin, to separate the curds from the liquid whey. The curd is pressed, optionally salted and cured by keeping them for a prescribed time at controlled temperature and humidity levels. Some cheeses come with a protective skin, or rind, others are dipped in wax. The longer a cheese is cured the harder the texture and the stronger the flavor. Most cheeses, such as cheddar are aged from one month to over a year.

The cheeses are often named after their original source or their physical characteristics. For example Cheddar is the name of an English village; Colby is in Wisconsin. Camembert was named by Napolean after the hamlet where it was first produced. Fontina cheese is named after Mont Fontin, which overlooks the Piedmont region in northern Italy. Liederkranz cheese is named after a New York singing group that raved about its taste. Port Salut cheese was named for the abbey to which the monks returned after the French Revolution-Port of Salvation. It is still made by Trappist monks in France according to their secret formula. Raclette was first used as a melting cheese in a Swiss specialty dish from which it takes its name. Swiss Emmentaler cheese is named after the river valley in central Switzerland where it was first made. Swiss cheese made in the United States or other countries cannot use the name "Emmentaler" and is thus called simply Swiss cheese. Some cheese names come from their shape such as Brick or Caciocavallo (the pear-shaped cheese from Italy). The blue cheese (spelled bleu in imported French cheese) signifies blue-green veins in the cheese.

Processed cheese is a mixture of shredded cheeses pasteurized together to stop them from ripening further, thereby keeping the flavor and texture uniform and increasing shelf life. There are three types of processed cheeses. Pasteurized process cheese, such as American cheese slices, contains the most actual cheese. Pasteurized process cheese food is about half cheese and half water mixed with another dairy product while pasteurized process cheese spread has the most water and is the most spreadable. Cold pack, or club cheese, is processed cheese that has not been heated and may be sweetened.Whey: A greenish-yellow fluid drained from the vat after the protein portion of milk is removed as cheese. It is mainly made up of lactose and small quantities of proteins. The antipollution laws prevent dumping of whey in the sewer system so cheese manufacturers found an ingenious way to make a few extra dollars. They sell whey to other processed food manufacturers who use it in their products as a hidden source of lactose. These products include snack drinks, wines, milk substitutes, imitation milks and various liquid meals, high protein beverages, frozen desserts, syrups, and candies, especially caramels.FormulasThe earliest commercial formulas were produced in Nathan Straus' laboratory in New York in 1912.

Most modern infant formulas used in this country, however, are adaptations of the product designed here in 1915 by H.J. Gerstenberger and his co-workers.

NATHAN STRAUS' LABORATORY INFANT FORMULAS, 1912

Age, weeks

#All values in ounces; *:barley or oat water; #: teaspoon

Few people realize that the world "formula" in infant feeding actually relates to algebra. During the early part of this century there were many problems associated with making milk drinks for infants, not the least of which were contamination with water, chalk and boric acid. The water used in diluting milk was often heavily contaminated. (Bottle feeding was further complicated by the unavailability of rubber nipples. Some rather unusual substitutes were used: linen and sponge, tubes and boat shaped bottles. It was not until the 19th century that the Goodyear Company developed rubber nipples.)

With strict government standards in the early '20s, however, cow's milk became safer to use. With that came elaborate formulas which included many "magical" factors. Each baby was dispensed a newly tailored formula and the mixtures of milks were compounded and dispensed like drugs. Minute variations of the composition of formula were believed to make the difference between whether it could be digested or not. Infant feeding became an exercise in mathematical biochemical engineering. In a 1904 pediatric text almost 2-1/2 page-long formulas are given to calculate needs of healthy infants. The volume of individual feedings was based on measurements of the stomachs of infant cadavers.

With the precise formulas also came the rigid timing of feeding infants. Feeding at fixed times was a cultural byproduct made possible by the invention of the clock. The modern trend, reverting back to nature, is to feed "on demand" instead of on schedule.The changes in the composition of infant formulas to bring it as close as possible to the composition of mother's milk are subject to strict government controls. As a substitute for human milk, a formula should provide:

. 7-16 % calories from proteins;

. 30-45 % calories from fats;

. 2-3 % calories from essential fatty acids;

. balance of calories from carbohydrates;

. about 20 calories per ounce.

For premature or low-weight infants (under six pounds), modified formulas are used. In these formulas, protein and mineral concentration is higher, lactose concentration is lower and fat is present in an easily digestible form. Caloric density is also higher (800-1000 kcal/liter). Infants weighing less than three pounds are fed through a nasal tube or through veins, requiring highly specialized formulations.The infant formulas also come fortified with iron, a formulation seriously criticized by many. Most formulas use lecithin as emulsifier and carrageenan as stabilizer and thickener. One formula uses corn starch for this purpose. Only approved ingredients go into infant formulas (appendix 6.2).

In the U.S., any infant food containing two or more ingredients must be labeled with the common or usual name of each ingredient along with its source. Infant formula must also specify moisture, protein, fat, available carbohydrate, ash and crude fiber along with caloric load and added vitamins and minerals. A warning, "this product should not be used as the sole source of protein in the infant diet," must appear if protein is less than 1.8 grams/100 kcal. Also, if essential fatty acids such as linoleic acid do not provide at least two percent of calories, this must be so labeled. The formula manufacturers have also adopted packaging standards and label designs to minimize confusion in the identification of ready-to-feed, concentrate or powdered forms.The science of formula making has reached a high peak in recent years, yielding some of the best alternatives to human milk. Yet, like other substitutes, these are still a second-best choice when it comes to providing ideal nutrition to the newborn.

The most obvious advantages of the use of formula is the consistency of nutrition, reduced level of environmental pollutants, convenience and participation of the father in infant feeding. On the other hand, the obvious disadvantages are over-feeding, microbiologic contamination and errors in mixing. The major disadvantage in the use of fomulas is the loss of physiologic interaction with mother--a system by which infants communicate with their mothers. What's missing in the formulas? To say the least, a lot. Although formulas offer excellent alternatives to human milk when needed, there are ingredients in human milk that are difficult to duplicate in formula because we have not yet identified them. One of these missing ingredient is the immune factor, vital in the protection against diseases in the newborn. Science now suggests that many of these components can be isolated from cow's milk and added to infant formula. Some can be synthesized or produced in the laboratory. A major sources of the immune factor is natural cheese whey. Many immune factors found in human milk can be commercially prepared and added to formulas. Several clinical trials sponsored by formula manufacturers are underway to test these factors in humans. One such test examines their effectiveness in preventing infant diarrhea.

A Japanese patent describes how to add the bifidus factor to milk. Other procedures describe how to sensitize cows to various bacteria found in infant feces thereby promoting production of specific immune factors in cow's milk.

Additional research concerns the processing out of allergans in the formulas. Japanese scientists do it by predigesting casein with enzymes and then isolating the nonallergenic fraction by a special filtration process.

Infant formulas also lack picolinic acid, responsible for enhancing zinc absorption in human milk.

Human milk contains a substantial quantity of cholesterol (about 14 milligrams/100 milliliter ). Although the role of cholesterol in infant growth is debatable, formulas need fortification with cholesterol. Cholesterol is essential for body metabolism, essential for brain and tissue development, alongwith serving as a precursor to essential hormones and vitamins.

One ingredient that is needed in all formulas is DHA, a fatty acid associated with brain development in infants. It is disappointing that formulas are deficient in such essential elements as DHA, picolinic acid, taurine and cholesterol. Lactose, the ingredient essential for brain development is also missing in soy-based formulas.Formula is also criticized because of the possibility of human error in its use. For example, a concentrate given without diluting may cause blockage of intestines because of thick curdling. Similarly, using contaminated water or utensils in the prepartion of formula would spread infections. These dangers, more prevalent in less educated societies, are, however, less threatening than other tribal or ancedotal practices of preparing ethnic milk substitutes. Cassava, a major staple of Africa, generates cyanide poisoning unless properly fermented. Peas of Lathyrus, a common food in India, causes permanent paralysis unless boiled for at least 30 minutes. There are several types of infant formulas:

MILK-BASED: Recommended for routine use, proteins in these formulas come from nonfat cow's milk, fat from vegetable sources and carbohydrate from lactose.

MILK-WHEY-BASED: Recommended for routine use, with components similar to milk-based formulas but with lower protein and mineral content, higher carbohydrate content, and altered fat composition. This is done by mixing milk, whey components, vegetable fat, and corn syrup solids. Several highly technical and patented processes are used for these preparations. The dried products from these formulas are prepared by evaporating water under vacuum.

SOY-BASED: Recommended when infant is sensitive to cow's milk, proteins in these formulas come from soy-isolate, fat from vegetable oils and carbohydrate from corn syrup or sucrose. Soybean formulas and other soy foods are the most significant alternatives to milks and other foods. These are discussed in detail in the following chapter, The Soybean Revolution.

HYDROLYSATE FORMULAS: These formulas are recommended for protein sensitivity and galactosemia. Smaller proteins and amino acids cause less allergic reactions. Hydrolyzed proteins for these formulas are made from casein or whey. The casein in milk can be predigested using enzymes making it readily assimilated and much less allergenic, such as Nutramigen and Pregestimil by the Mead-Johnson Company, both of which contain corn oil and have no lactose. Pregestimil is also suitable for patients who have difficulty absorbing fats. Most of these products do not taste as good as milk. Other components of the formula come from tapioca, corn oil, corn syrup, etc.

MODULE FORMULAS: Chicken proteins or beef serum hydrolysate in combination with carbohydrate from tapioca starch and sucrose, fat from sesame oil or beef-heart fat, and vitamins make these formulas. These formulas provide high grade proteins but may be more allergenic than other formulas. These are recommended in cow's milk sensitivity and galactosemia.

LACTOSE-FREE, CASEIN-BASED FORMULAS:

These formulas are suitable for those who are intolerant to lactose or other cow's milk proteins. However, because of their high protein, low cystine and low energy content, none of these products is suitable for infants under six months of age.

ELEMENTAL DIETS: Milk proteins can be replaced by synthetic amino acids such as in protein-free Vivonex (Eaton). These diets are recommended for those who are also allergic to other milk substitutes or where a patient may have multiple allergies.

VEGETABLE DIETS: Preparations made from vegetables, fruits, legumes and cereals are particularly useful in multiple food allergies such as Poi, a paste made of taro (Colcasia esculenta). These diets are not recommended as complete food since they often lack essential proteins.

HOME-MADE PREPARATIONS: It is often impossible to avoid milk components in commercial foods, since they may not always appear on the label. For this reason and also because infants may be allergic to various chemical additives in the commercial preparations, it may be better to prepare foods at home using simple ingredients, after consulting a dietitian.In conclusion, breast-feeding must be ranked above the bottle. However, if a substitute is needed, infant formulas take preference over cow's milk. Formulas can help overcome malnutrition with reduced exposure to hazard of heart disease, cancer, kidney disease and many other dread diseases caused by the use of cow's milk as discussed in later chapters of this book.

Despite all disadvantages, formulas offer a plausible alternate to breast-feeding. Purists have often condemned infant formulas because they are not "natural." Nothing contained in the formulas is created by man, he has only gathered these ingredients for the convenience of the mother and the health of the infant. We must remember that cow's milk is natural only to a calf not a human being. Undoubtedly, there are deficiencies in infant formulas, some due to lack of scientific knowledge, others to economic reasons. Nevertheless, infant formula producers are diligently working to improve their product. In the not too distant future, man will be able to produce a real substitute to human milk, but it is definitely not going to be derived from the cow's udder.

With time, say a few hundred million years, the reduced use of breasts to feed infants will cause these organs to eventually decrease in size and disappear like the tails we used to have not too long ago. Man is an essential part of his own evolution and there is no reason to make any deliberate efforts in changing its course. A breast-less society will bear its own esthetic and sexual appeal but we cannot even begin to visualize it--at least not for now.

APPENDIX 6.1

APPENDIX 6.2

HUMAN MILK BANKS IN THE U.S.

St. Mary's Memorial Milk Bank, Rogers, AK (501-636-0200)

Santa Barbara Medical Foundation, Santa Barbara, CA (805-964-6211)

Mother's Milk Unit, San Jose, CA (408-998-4550)

Women's Hospital at St. Lukes, Denver, CO (303-869-1888)

Wilmington Medical Center, Wilmington, DE (302-428-2300)

Georgetown University Medical Center, Washington, DC (202-625-6455)

The Medical Center, Columbus, GA (404-324-4711)

Kapiolani-Children's Medical Center, Honolulu, HIBabies Milk Bank of Chicago, Naperville, IL (312-420-2172)

Iowa Methodist Medical Center, Des Moines, IA Central Baptist Hospital, Lexington, KY (606-278-3411)

University of Kentucky Human Milk Bank, Lexington, KY (606-233-8994)

Worcester Hahnemann Hospital, Worcester, MA (617-792-8295)

Children's Hospital, St. Paul, MN (623-398-8667)

Dartmouth Medical Center, Hanover, NH Milk for LIfe, Inc. Greenville, NY (518-966-4182)

Babies Hospital, New York, NY (212-694-2223)

Northshore University Hospital, Manhassett, NY (516-562-4447)

Bikur Cholim of Rockland County, Monsey, NY (914-425-7877)

Piedmont Mother's Milk Bank, Raleigh, NC (919-755-8599)

Portsmouth Area Mother's Milk Program, Lucasville, OH (614-259-4918)

St. Francis Hospital, Tulsa, OK (918-494-6508)

Rogue Valley Memorial Hospital, Medford, OR (503-773-6281)

Eastern PA Milk Bank, Bethlehem, PA (215-691-6462)

Mother's Milk Drive, Austin, TX (512-255-5560)

Jefferson Davis Hospital, Houston, TX (713-799-4834)Texas Children's Hospital, Houston, TX (713-791-2011)

Mother's Milk Drive, Houston, TX (713-943-7860)

Mother's Milk Bank of Victoria, Victoria, TX (512-573-0885

Milk Banking Association of North America.

TYPICAL INGREDIENTS OF INFANT FORMULAS

Functional Components: Water, Corn syrup. Soy protein isolate, Coconut oil, Soybean oil, Modified corn starch, Mono- and diglycerides, Soy lecithin, Carrageenan.

Amino acid sources: L-methionine, Soy proteins

Vitamin sources: Vitamin A palmitate, Vitamin D3, Alphatocopheryl acetate, Phytonadione, Ascorbic acid, Thiamine hydrochloride/chloride, Riboflavin, Cyanocobalamin, Niacinamide, Calcium pantothenate, Pyridoxine hydrochloride, Biotin, Folic acid, Choline chloride

Mineral sources: Calcium phosphate, tribasic, Cupric sulfate, Ferrous sulfate, Magnesium chloride, Potassium chloride, Potassium citrate,
Zinc sulfate, Manganous chloride