REVIEW ARTICLE

Breastfeeding for Gut Infant Health

Badriul Hegar*, Yvan Vandenplas**
*Division of Gastroenterology-Hepatobiliary, Department of Child Health, Faculty of Medicine,
Universitas Indonesia/Dr. Cipto Mangunkusumo General National Hospital, Jakarta
**Department of Pediatrics, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium

Corresponding author:
Badriul Hegar. Division of Gastroentero-hepatology, Department of Child Health, Dr. Cipto Mangunkusumo General
National Hospital. Jln Diponegoro No 71 Jakarta Indonesia. Phone: +62-21-3907742; Facsimile:+62-21-3907743.
E-mail: badriulh@gmail.com

ABSTRACT

Infants react sensible to dietary changes because the gut physiology and functionality is not fully mature. The
first few months of life is the 'window of opportunity' for optimal physical growth and development, cognitive
development, and emotional and social development. Exclusive breastfeeding is recommended for the first 6
months of life. Breast milk is important for the maturation of the infant’s digestive system. Potentially protective
factors are present in higher amounts in feces from breast-fed infant than from formula-fed infants. The amount of
intestinal bifidobacteria in breastfed infants is higher than in formula-fed babies. Mother's milk protects against
infection because it contains different factors with immologic properties. The differences in protein fractions
between human and cow milk are impressive. The human milk oligosaccharides are the third most important
nutritional component are fermented in the colon, making the environment in the colon suitable for the growth
of bifidobacteria and lactobacillus.

Keywords: breastfeeding, breast milk, window of opportunity, gut protection, optimal growth

ABSTRAK

Bayi bereaksi sensitif terhadap perubahan pola makan karena fisiologi dan fungsi usus yang belum sepenuhnya
matang. Beberapa bulan pertama kehidupan adalah 'window of opportunity' untuk pertumbuhan fisik dan
perkembangan optimal, perkembangan kognitif, serta perkembangan emosional dan sosial. Pemberian air
susu ibu (ASI) eksklusif dianjurkan untuk 6 bulan pertama kehidupan. ASI penting untuk pematangan sistem
pencernaan bayi. Faktor yang berpotensi protektif hadir dalam jumlah yang lebih tinggi pada feses bayi yang
diberi ASI daripada bayi yang diberi susu formula. Jumlah bifidobakteri usus pada bayi yang diberi ASI lebih
tinggi daripada bayi yang diberi susu formula. Air susu ibu melindungi dari infeksi karena mengandung faktor
yang berbeda, adanya sifat imologis. Perbedaan fraksi protein antara ASI dan susu sapi sangat mengesankan.
Oligosakarida susu manusia adalah komponen nutrisi terpenting ketiga yang difermentasi di usus besar, membuat
lingkungan di usus besar cocok untuk pertumbuhan bifidobakteri dan lactobacillus.

Kata kunci: menyusui, air susu ibu (ASI), window of opportunity, perlindungan usus, pertumbuhan optimal

INTRODUCTION
recommended that infants be exclusively breastfed for
Human milk is the first choice infant feeding. The 4-6 months with the introduction of complementary
exclusive breastfed infant with a normally diversified foods (any fluid or food other than breast milk).
maternal dietary intake is the gold standard. Before Thereafter, in 2001, after a systematic review and
2001, the World Health Organization (WHO) expert consultation, this advice was changed and

42 The Indonesian Journal of Gastroenterology, Hepatology and Digestive Endoscopy

 Breastfeeding for Gut Infant Health

exclusive breastfeeding is now recommended for the Optimal Growth

first 6 months of life.1
Exclusive breastfeeding is nutritionally complete
Many data showed that formule feeding increased
for term infants and results in optimal growth. Mother's
the incidence of cow's milk protein allergy (CMPA) or
milk contains nutrients of high biological value,
atopic manifestation compared to breastfeeding (short-
stimulates the development of natural immunity, and
term prevention). The long-term benefit of a reduced
is above all practical, economical, convenient, and
inidence of atopic disease, cardio-vascular disease, and
rewarding because it stimulates the mother to child
other diseases are still on going study.
bonding.
The digestive system of a newborn is immature.
Window of Opportunity
Infants may lose up to 10% of their birth weight in
A window of opportunity is a period of time during the first days of his life, as they adjust using their own
which an intervention will result in short and long digestive system. The optimal infant feeding need to
term benefit, and is thus a critical period. The first contain a large amount of calories in a relatively small
few months of life is the 'window of opportunity' for; volume of food. Breast milk, with a high fat content, is
(1) Optimal physical growth and development (e.g. the most efficient way for infants to meet their caloric
weight and height gain); (2) Cognitive development needs.4
(e.g. language, non-verbal learning, attention, problem During the first 4-6 months of life, the digestive
solving, IQ); (3) Emotional and social development system undergoes enormous changes as it develops the
(e.g. emotional control, behavioral adaptation, social ability to produce enzymes to digest food, to develop
interaction). tolerance and antibodies offering protection. During
Infants react sensible to dietary changes because the first months of life, infants can not handle solid food
gut physiology and functionality is not fully mature. or large feedings, because their intestinal tract is not
The mucosa of the gut is not yet fully closed (relative suficiently developed and mature. Breast milk is a
absence of „tight junctions“); therefore large molecules food designed especially for infants to allow adapted
such as intact proteins, (pathogenic) bacteria pass maturation of the gastrointestinal tract.
relatively easy through the small intestinal mucosa into Lipase and bile salts, which aid in fat digestion, do
the bloodstream. The immune system is not yet fully not reach full levels until the age of 6 months. Human
developped as well. The first few months of life is a milk is rich in lipids (98% triglyceride), but contains
vulnerable period, in which a child’s immature immune bile salt-stimulated lipase which is an enzyme similar
system is constantly exposed to over one billion of to pancreatic lipase.4,5 Proteins and amino acids are
germs.2 Children with a poor immune system will be needed by infants in relatively important quantities to
more vulnerable to infection, including respiratory tract support their rapid growth rate. Protein requirements
infection, otitis media and gastroenteritis. An infant are met by adequate intake of breast milk. Breast milk
that suffers frequent infections will miss the window contains a variety of proteases, including trypsin,
of opportunity to develop its full potential.2 elastase, plasmin, etc that start digesting proteins as
soon as they are secreted. Breast milk also contains
Suboptimal Exclusive Breastfeeding antiproteases that serve to protect milk proteins from
degradation. The process of protein secretion and
Non-exclusive breastfeeding is associated with an
digestion in the mammary glands, depends on the
increased risk for many diseases such as necrotizing
balance of proteases and antiprotease.6 Unmodified
enterocolitis, otitis media, gastroenteritis, lower
cow’s milk is not suitable to feed an infant because
respiratory tract infections, atopic dermatitis, sudden
it is nutrionally unbalanced, has a high renal solute
infant death syndrome, childhood asthma, leukemia,
load (three times as much protein as as human milk,
type 1 diabetes mellitus and childhood obesity.
an excess of sodium), too low in iron, and fat that is
A socio-economic analysis concluded that the
difficult to be digested by the infant's gastrointestinal
burden of suboptimal breastfeeding is enormous: if 90%
system.
of all families could comply with the recommendation
to breastfeed exclusively for 6 months in the USA,
Gut Protection
this would result for the government in savings of 13
billion dollars per year on health care cost and prevent Breast milk is important for the maturation of
almost a thousand infant deaths.3 the infant’s digestive system. Colonies of beneficial

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Badriul Hegar, Yvan Vandenplas

bacteria will develop in the intestine as a consequence First, cow's milk contains three times more protein than
of the presence of human milk oligosacchardes human milk. Breast milk contains 60% whey and 40%
and intestinal grorwth fatcors in mother's milk. casein while cow’s milk contains 20% whey and 80%
These beneficial bacteria help prevent an invasion casein. Whey breast milk contains mostly lactoferrin,
by pathogens and contribute to a heatly maturation alpha lactalbumin and immunoglobulin, whereas whey
process. The protective mucosal barrier in infant cow’s milk contains mostly Beta-lactoglobulin.11 A
is immature and puts infant at risk for infection. randomized clinical trial showed low protein in infant
Antibodies in breast milk help protect infants until formula is associated with lower weight up to age
the digestive mucosa matures and increases the ability 2 year, more similar to the weight gain in breastfed
to produce its own antibodies around the age of 4-6 infants.12,13 There is no convincing scientific evidence
months. that avoidance or delayed introduction of potentially
Secretory Immunoglobulin A (sIgA) constitutes the allergenic foods, such as fish and eggs would reduce
first line of defense, protecting the intestinal epithelium allergies, either in infants considered at increased
from enteric toxins and pathogenic microorganisms. risk for the development of allergy or in those not
sIgA promotes the clearance of antigens from the gut by considered to be at increased risk.14 If the incidence
blocking their access to epithelial receptors, entrapping of allergic manifestaions is higher in formula than
in mucus, and facilitating their removal by peristaltic in breastfed infants, is still a matter of debated. This
and mucociliary activities.7 sIgA in breast milk is is mainly due to the fact that breatsfeeding cannot
capable of binding commensal bacteria and may be be randomized, and that the most allergic families
involved in the progressive and controlled establishment breastfeed more frequently and longer.
microbiota of the newborn. The microbiota stimulates Mother's milk protects against infection because it
the maturation of the gut-associated-lymphoid-tissue contains different factors with immologic properties.
(GALT), resulting in the production of IgA with both Therefore, mothers milk influences the longterm
a limited affinity and repertoire to redundant epitopes immune response and risk for the development of
on gut microorganisms.8 auto-immune disease. sIgA, lactoferin, lysozym,
Potentially protective factors are present in higher lactoproxidase, oligosaccharides, bifidus factor,
amounts in feces from breast-fed infant than from etc act as anti-microbial agents; cytokines (IL-10
formula-fed infants. The sIgA level in breastmilk is and TGFB) and anti-idiotypic antibodies play an
high (1-2g /L in colostrum and 0.5-1 g/L in mature important role in the development of tolerance and
breastmilk). The sIgA levels in the feces of breastfed priming; macrophages, neutrophils, lymphocytes,
infants (0.11 + 0.07 mg/mL) was higher than in the cytokines, growth factors, hormones, nucleotides, milk
feces of standard formula-fed infants (0.03 + 0.01 mg/ peptide, adhesion molecules influence the immune
mL) at the age of one month of life.9 development, and TNF alpha and Il-6 receptors CD4,
Gut bacteria modulate the immune response. The cytokines, adhesion molecules, LC-PUFA, IL-1
amount of intestinal bifidobacteria in breastfed infants receptor antagonist, lactoferin, hormone and growth
is higher than in formula-fed babies. Mother's milk factors, etc. have anti-inflamatory properties.15
influences the specie sand amount of gut bacteria Lactoferrin is an iron binding protein, facilitating
through multiple factors, such as human milk iron uptake, and is resistant to trypsin digestion.
oligosaccharides, immunology active components, Lactoferin has a bacteriostatic effect since it has
nutrient content (e.g low protein and low phosphate), a high iron affinity and competition for iron with
etc. This microbiota will stimulate the reproduction of iron-dependant microbes. Lactoferrin has a strong
sIgA against some gastrointestinal pathogens such as bactericidal effect (independent from iron saturation),
E. coli, V. cholerae, C. difficile, Salmonella, Rotavirus, at least partly due to lactoferricin (bactericidal peptide
C. albicans.10 formed during digestion). Lactoferrin also decreases
the intestinal cell attachment of Enteropathogenic E.
Good Reason for Breastfeeding coli (EPEC). In vitro, lactoferricin is active against
Casein is a milk protein with diverse biologic HIV and C. albicans.16
consequences. What is good for the goose may be good Essential fatty acids (e.g. linoleic acid, alpha
for the gander, but what is good for the cow could be linolenic acid) can not be synthesized by the body, must
harmful to the human infant. The differences in protein therefore be supplied in adequate amounts by feeding.
fractions between human and cow milk are impressive. Essensial fatty acids are precursors of a number of

44 The Indonesian Journal of Gastroenterology, Hepatology and Digestive Endoscopy

 Breastfeeding for Gut Infant Health

long-chain poly-unsaturated fatty acids (LCPUFAs). infections, especially infections of gastrointestinal and
The long-chain poly-unsaturated fatty acids consist upper respiratory tract.22 Nucleotides also respond
of arachidonic acid (ARA) and Docosohexanoic acid better to diphtheria, polio and influenza immunization.23
(DHA). Arachidonic acid acts in all cell membran as
modulator of cell immunity, and is pro-inflammatory.
CONCLUSION
Docosohexanoic acid is present mainly in neuronal
tissue (brain, retina) and has also an important role Human milk is the best, complete nutrition for
on the development of immune function, and has infants. It has anti-infective and anti-inflammatory
anti-inflammatory properties. The levels of DHA in effects by modulating the development of the immune
human milk lipids reflect the dietary intake of the response. Numerous human milk components and
mother. World-wide, the mean ratio of ARA and their interaction are involved in this complex process.
DHA in human milk is 1: 1, what ensures an adequate Research is neeeded to better understand the short
ARA status even in presence of DHA. Excessive and longterm effects of these specific nutrients and
LC-PUFA supplementation may induce a risk for breastfeeding as a whole. Opportunities for innovations
metabolic oxidation. ARA is efficiently metabolised in infant formula exist since many outcomes in
from linoleic acid. Excesses of ARA may lead to formula-fed infants differ from those in breastfed
undesirable inflammatory processes. Essential fatty populations. The development of these innovations
acids may possibly enhance the beneficial actions of with relevant outcome effects is complex, costly and
probiotics since LC-PUFAs promote the adhesion of time consuming.
probiotics to mucosal surfaces which increases their
health-promoting.17 Some studies showed abnormal
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46 The Indonesian Journal of Gastroenterology, Hepatology and Digestive Endoscopy