Karleen, you mentioned that the value of 
exclusive breastfeeding vs mixed feeding is known 
to be protective against HIV transmission, and 
that's quite true.  The first paper was published 
by Anna Coutsoudis in 1999, with a follow-up in 
2001 and then the results were confirmed by Iliff 
et al in the ZVITAMBO study published in 
2005.  But the special protection against other 
diseases associated with exclusive breastfeeding 
was known before that - HIV was just one more 
that others applied this knowledge to, eg 
Elizabeth Preble and Ellen Piwoz may have been 
amongst the first to make the suggestion (in 
1998) that  EBF might be protective in the 
context of HIV.  Looking through their writings 
and digging around to find out what other studies 
have been done on the difference in health 
outcomes between exclusive and 
predominant/partial breastfeeding in the newborn 
period, many sources seem to lead back to the same few studies:

A Brazilian study showed 5-fold and 2-fold 
increased mortality due to diarrhea and 
respiratory infections, respectively, in infants 
aged birth to 2 mo who were given breast milk 
plus milk supplements vs those exclusively 
breastfed, after controlling for reverse 
causality (Victora CG, Smith PG, Vaughan JP, et 
al. Evidence for protection by breast-feeding 
against infant deaths from infectious diseases in 
Brazil. Lancet 1987;2:319–22.)

A large study from Bangladesh showed a reduction 
of mortality due to acute respiratory infection 
with exclusive breastfeeding, beyond its role in 
preventing infectious diseases due to 
contaminated food, which also contribute to the 
strong protection against diarrhoea.  (Arifeen S, 
Black RE, Antelman G, Bacqui A, Caulfield L, 
Becker S. Exclusive breastfeeding reduces acute 
respiratory infection and diarrhea deaths among 
infants in Dhaka slums. Pediatrics 2001;108:E67.)

A study from Pakistan reported a 3-fold reduction 
in risk of early neonatal sepsis due to 
exclusively vs partial breastfeeding  (Bhutta ZA, 
Ysuf K. Early onset neonatal sepsis in Pakistan: 
a case control study of risk factors in a birth 
cohort. Am J Perinatol 1997;14:577–81.)

Risks for neonates of of prelacteal feeds, eg 
hypernatremia,(Akre J. Infant feeding: the 
physiological basis. Bull World Health Organ 
1989;67(suppl):1–108)  acidosis (de L Costello 
AM, Pal DK, Manandhar DS, Rajbhandari S, Land JM, 
Patel N. Neonatal hypoglycaemia in Nepal 2: 
availability of alternative fuels. Arch Dis Child 
Fetal Neonatal Ed 2000;82:F52–8.) and 
hypogycaemia (Oppe TE, Redstone D. Calcium and 
phosphorous levels in healthy newborn infants 
given various types of milk. Lancet 1968;1:1045–8.)

Pamela Morrison IBCLC
Rustington, England

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