Precisazione su allattamento

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Dott. Salvatore Annona

Specialista in Ginecologia e Ostetricia

Precisazione:

Sorprendentemente ho ricevuto una contestazione, con tanto di minacce legali e/o di ricorrere al mio Ordine professionale di appartenenza, per alcune mie affermazioni riguardo l'allattamento. In particolare è stato contestato un mio presunto "Articolo" in cui avrei dato delle informazioni errate e non supportate da adeguata letteratura. Mi occorre quindi precisare che nel mio sito non esiste alcun "Articolo" avente questo tema. Vi sono soltanto, limitatamente a questa sezione, delle domande che mi hanno inviato alcune utenti che hanno chiesto specificamente di esprimere una mia opinione.

Pertanto tengo a precisare che sicuramente il latte materno costituisce il miglior alimento per il neonato ed il lattante e che l'Organizzazione Mondiale della Sanità promuove l'allattamento materno esclusivo al seno fino ai 6 mesi e che è importante inoltre che il latte materno rimanga la scelta prioritaria anche dopo l’introduzione di alimenti complementari, fino ai due anni di vita ed oltre, e comunque finché mamma e bambino lo desiderino.

Per completezza riporto i 10 passi UNICEF-OMS

L'UNICEF e l'OMS hanno redatto un decalogo di misure che ogni struttura sanitaria deve dimostrare di rispettare prima di poter essere riconosciuta «Ospedale Amico dei Bambini».

Definire un protocollo scritto per l'allattamento al seno da far conoscere a tutto il personale sanitario

Preparare tutto il personale sanitario per attuare compiutamente questo protocollo

Informare tutte le donne in gravidanza dei vantaggi e dei metodi di realizzazione dell'allattamento al seno

Mettere i neonati in contatto pelle a pelle con la madre immediatamente dopo la nascita per almeno un’ora e incoraggiare le madri a comprendere quando il neonato è pronto per poppare, offrendo aiuto se necessario

Mostrare alle madri come allattare e come mantenere la secrezione lattea anche nel caso in cui vengano separate dai neonati

Non somministrare ai neonati alimenti o liquidi diversi dal latte materno, tranne che su precisa prescrizione medica

Sistemare il neonato nella stessa stanza della madre ( rooming-in ), in modo che trascorrano insieme ventiquattr'ore su ventiquattro durante la permanenza in ospedale

Incoraggiare l'allattamento al seno a richiesta tutte le volte che il neonato sollecita nutrimento

Non dare tettarelle artificiali o succhiotti ai neonati durante il periodo dell'allattamento

Promuovere la collaborazione tra il personale della struttura, il territorio, i gruppi di sostegno e la comunità locale per creare reti di sostegno a cui indirizzare le madri alla dimissione dall’ospedale.

Allo stesso tempo preciso che la mia opinione in merito agli allattamenti prolungati oltre gli 8 mesi rimane una mia opinione e non costituisce alcuna direttiva e/o esortazione a non allattare per periodi più prolungati. La mia opinione vuole solo trovare un compromesso fra utilità del bambino e salute psico-fisica della donna e della famiglia intera, integrando in questo giudizio personale l’insieme di tutti gli aspetti e non uno per uno. Se esiste letteratura che dimostra benefici innegabili per mamma e bambino anche per allattamenti prolungati, esiste anche letteratura che dichiara apertamente che non sempre è dimostrato che vi siano solo benefici. E la stessa letteratura raccomanda che dopo i 6 mesi l’allattamento, che può, ripeto può essere prolungato fino ai due anni, deve comunque essere integrato da altri alimenti, in quanto l’allattamento esclusivo al seno dopo i 6 mesi è controverso. A dimostrazione di ciò riporto alcuni lavori scientifici:

Arch Pediatr. 2013 Nov;20 Suppl 2:S29-48. doi: 10.1016/S0929-693X(13)72251-6.

[Breastfeeding: health benefits for child and mother].

[Article in French]

Comité de nutrition de la Société française de pédiatrie, Turck D1, Vidailhet M2, Bocquet A3, Bresson JL4, Briend A5, Chouraqui JP6, Darmaun D7, Dupont C4, Frelut ML8, Girardet JP8, Goulet O4, Hankard R9, Rieu D10, Simeoni U11.

Author information

Abstract

The prevalence of breastfeeding in France is one of the lowest in Europe: 65% of infants born in France in 2010 were breastfed when leaving the maternity ward. Exclusive breastfeeding allows normal growth until at least 6 months of age, and can be prolonged until the age of 2 years or more, provided that complementary feeding is started after 6 months. Breast milk contains hormones, growth factors, cytokines, immunocompetent cells, etc., and has many biological properties. The composition of breast milk is influenced by gestational and postnatal age, as well as by the moment of the feed. Breastfeeding is associated with slightly enhanced performance on tests of cognitive development. Exclusive breastfeeding for at least 3 months is associated with a lower incidence and severity of diarrhoea, otitis media and respiratory infection. Exclusive breastfeeding for at least 4 months is associated with a lower incidence of allergic disease (asthma, atopic dermatitis) during the first 2 to 3 years of life in at-risk infants (infants with at least one first-degree relative presenting with allergy). Breastfeeding is also associated with a lower incidence of obesity during childhood and adolescence, as well as with a lower blood pressure and cholesterolemia in adulthood. However, no beneficial effect of breastfeeding on cardiovascular morbidity and mortality has been shown. Maternal infection with hepatitis B and C virus is not a contraindication to breastfeeding, as opposed to HIV infection and galactosemia. A supplementation with vitamin D and K is necessary in the breastfed infant. Very few medications contraindicate breastfeeding. Premature babies can be breastfed and/or receive mother's milk and/or bank milk, provided they receive energy, protein and mineral supplements. Return to prepregnancy weight is earlier in breastfeeding mothers during the 6 months following delivery. Breastfeeding is also associated with a decreased risk of breast and ovarian cancer in the premenopausal period, and of osteoporosis in the postmenopausal period.

PMID: 25063312

[PubMed - indexed for MEDLINE]

Traducendo le parti salienti, si fa riferimento ad allattamento esclusivo al seno fino a 6 mesi che può essere prolungato fino a 2 anni, ma che dopo i 6 mesi deve essere integrato. Vi sono innumerevoli benefici, ma non sono stati dimostrati effetti benefici sulla morbidità e morbilità cardiovascolare delle madri.

Allergy Asthma Proc. 2014 Jan-Feb;35(1):66-70. doi: 10.2500/aap.2014.35.3716.

Effect of prolonged breast-feeding on risk of atopic dermatitis in early childhood.

Hong S1, Choi WJ, Kwon HJ, Cho YH, Yum HY, Son DK.

Author information

Abstract

The effect of breast-feeding on the risk of developing atopic disease remains controversial. This study is an investigation of the effect of breast-feeding on current atopic dermatitis (AD) among Korean children. This cross-sectional study of children's histories of current AD and environmental factors was completed by the subjects' parents. The subjects included 10,383 children aged 0-13 years in Seoul, Korea, in 2008. The diagnostic criteria of the International Study of Asthma and Allergies in Childhood were applied in this study. Adjustments were performed for age, gender, maternal education, smoking in the household, relocation to a new house within 1 year of birth, and parental history of atopic disease. After adjustment for confounders, age and duration of maternal education were found to be inversely associated with the prevalence of AD. Among subjects aged ≤5 years, the prevalence of AD was positively associated with the duration of breast-feeding (p < 0.001). However, there was no significant association between AD and breast-feeding among children >5 years of age. Regardless of parental history of atopic diseases, breast-feeding >12 months was a significant risk factor for AD. The effect of breast-feeding differed by age group. Prolonged breast-feeding increased the risk of AD in children <5 years of age, regardless of parental history of atopic diseases.

PMID:

24433599

[PubMed - indexed for MEDLINE]

Traducendo: In questo studio addirittura viene riconosciuto un aumento dell'incidenza di dermatite atopica in caso di allattamenti superiori ai 12 mesi, entro i 5 anni di età del bambino.

Am J Clin Nutr. 2013 Oct;98(4):1048-56. doi: 10.3945/ajcn.113.065300. Epub 2013 Aug 14.

Effects of an intervention to promote breastfeeding on maternal adiposity and blood pressure at 11.5 y postpartum: results from the Promotion of Breastfeeding Intervention Trial, a cluster-randomized controlled trial.

Oken E1, Patel R, Guthrie LB, Vilchuck K, Bogdanovich N, Sergeichick N, Palmer TM, Kramer MS, Martin RM.

Author information

Abstract

BACKGROUND:

Differences between mothers who do and do not succeed in breastfeeding are likely to confound associations of lactation with later maternal adiposity.

OBJECTIVE:

We compared adiposity and blood pressure (BP) in women randomly assigned to an intervention to promote prolonged and exclusive breastfeeding or usual care.

DESIGN:

We performed a cluster-randomized trial at 31 hospitals in Belarus in 1996-1997.

RESULTS:

Of 17,046 women enrolled at delivery, we assessed 11,867 women (69.6%) at 11.5 y postpartum. The prevalence of exclusive breastfeeding ≥3 mo was 44.5% in 6321 women in the intervention group and 7.1% in 5546 women in the control group. At 11.5 y postpartum, mean (±SD) body mass index (BMI; in kg/m(2)) was 26.5 ± 5.5, the percentage of body fat was 33.6% ± 8.3%, and systolic BP was 124.6 ± 14.6 mm Hg. On intention-to-treat analysis (without imputation) with adjustment for clustering by hospital, mean outcomes were lower in intervention compared with control mothers for BMI (mean difference: -0.27; 95% CI: -0.91, 0.37), body fat (-0.49%; 95% CI: -1.25%, 0.27%), and systolic BP (-0.81 mm Hg; 95% CI: -3.33, 1.71 mm Hg), but effect sizes were small, CIs were wide, and results were attenuated further toward the null after adjustment for baseline characteristics. Results were similar in sensitivity analyses [ie, by using conventional observational analyses disregarding treatment assignment, instrumental variable analyses to estimate the causal effect of breastfeeding, and multiple imputation to account for missing outcome measures (n = 17,046)].

CONCLUSION:

In women who initiated breastfeeding, an intervention to promote longer breastfeeding duration did not result in an important lowering of adiposity or BP. This trial was registered at clinicaltrials.gov as NCT01561612 and at Current Controlled Trials as ISRCTN37687716.

PMID:

23945719

[PubMed - indexed for MEDLINE]

PMCID:

PMC3778859

Traducendo: In questo studio viene affermato che incentivare un allattamento più prolungato non si traduce in una importante diminuzione di adiposità o della pressione arteriosa delle madri.

Cochrane Database Syst Rev. 2002;(1):CD003517.

Optimal duration of exclusive breastfeeding.

Kramer MS(1), Kakuma R.

Author information:

(1)McGill University, Faculty of Medicine, 1020 Pine Avenue West, Montreal,

Quebec, Canada, H3A 1A2. mikek@epid.lan.mcgill.ca

Update in

Cochrane Database Syst Rev. 2012;8:CD003517.

BACKGROUND: : Although the health benefits of breastfeeding are widely acknowledged, opinions and recommendations are strongly divided on the optimal duration of exclusive breastfeeding. Much of the debate has centered on the so-called 'weanling's dilemma' in developing countries: the choice between the known protective effect of exclusive breastfeeding against infectious morbidity and the (theoretical) insufficiency of breast milk alone to satisfy the infant's energy and micronutrient requirements beyond four months of age. The debate over whether to recommend exclusive breastfeeding for four to six months versus 'about six months' has recently become heated and acrimonious.

OBJECTIVES: : The primary objective of this review was to assess the effects on child health, growth, and development, and on maternal health, of exclusive breastfeeding for six months versus exclusive breastfeeding for three to four months with mixed breastfeeding (introduction of complementary liquid or solid foods with continued breastfeeding) thereafter through six months. A secondary objective was to assess the child and maternal health effects of prolonged (greater than six months) exclusive breastfeeding versus exclusive breastfeeding for six months followed by mixed breastfeeding thereafter.

SEARCH STRATEGY: : Two independent literature searches were carried out, together comprising the following databases: MEDLINE (as of 1966), Index Medicus (prior to), CINAHL, HealthSTAR, BIOSIS, CAB Abstracts, EMBASE Medicine, EMBASE-Psychology, Econlit, Index Medicus for the WHO Eastern Mediterranean Region, African Index Medicus, Lilacs (Latin American and Caribbean literature), EBM Reviews-Best Evidence, the Cochrane Database of Systematic Reviews (The Cochrane Library Issue 3, 2000), and the Cochrane Controlled Trials Register (The Cochrane Library Issue 3, 2000). No language restrictions were imposed. The two searches yielded a total of 2,668 unique citations. Contacts with experts in the field yielded additional published and unpublished studies.

SELECTION CRITERIA: : We selected all internally-controlled clinical trials and observational studies comparing child or maternal health outcomes with exclusive breastfeeding for six or more months versus exclusive breastfeeding for at least three to four months with continued mixed breastfeeding until at least six months. Studies were stratified according to study design (controlled trials versus observational studies), provenance (developing versus developed countries), and timing of compared feeding groups (three to seven months versus later).

DATA COLLECTION AND ANALYSIS: : Two reviewers independently assessed study quality (using a priori assessment criteria) and extracted data.

MAIN RESULTS: : Twenty independent studies meeting the selection criteria were identified by the literature search: nine from developing countries (two of which were controlled trials in Honduras) and 11 from developed countries (all observational studies). The two trials did not receive high methodologic quality ratings but were nonetheless superior to any of the observational studies included in this review. The observational studies were of variable quality; in addition, their nonexperimental designs were not able to exclude potential sources of confounding and selection bias. Definitions of exclusive breastfeeding varied considerably across studies. Neither the trials nor the observational studies suggest that infants who continue to be exclusively breastfed for six months show deficits in weight or length gain, although larger sample sizes would be required to rule out modest differences in risk of undernutrition. The data are conflicting with respect to iron status, but at least in developing country settings where newborn iron stores may be suboptimal, suggest that exclusive breastfeeding without iron supplementation through six months may compromise hematologic status. Based primarily on an observational analysis of a large randomized trial in Belarus, infants who continue exclusive breastfeeding for six months or more appear to have a significantly reduced risk of one or more episodes of gastrointestinal infection. No significant reduction in risk of atopic eczema, asthma, or other atopic outcomes has been demonstrated in studies from Finland, Australia, and Belarus. Data from the two Honduran trials suggest that exclusive breastfeeding through six months is associated with delayed resumption of menses and more rapid postpartum weight loss in the mother.

REVIEWER'S CONCLUSIONS: : We found no objective evidence of a 'weanling's dilemma'. Infants who are exclusively breastfed for six months experience less morbidity from gastrointestinal infection than those who are mixed breastfed as of three or four months, and no deficits have been demonstrated in growth among infants from either developing or developed countries who are exclusively breastfed for six months or longer. Moreover, the mothers of such infants have more prolonged lactational amenorrhea. Although infants should still be managed individually so that insufficient growth or other adverse outcomes are not ignored and appropriate interventions are provided, the available evidence demonstrates no apparent risks in recommending, as a general policy, exclusive breastfeeding for the first six months of life in both developing and developed country settings. Large randomized trials are recommended in both types of setting to rule out small effects on growth and to confirm the reported health benefits of exclusive breastfeeding for six months or beyond.

PMID: 11869667 [PubMed - indexed for MEDLINE]

Traducendo: Questo lavoro è tratto dalla libreria Cochrane, che raccoglie i risultati della medicina basata sull’evidenza. Nelle conclusioni vi si legge che a fronte di indubbi benefici dell’allattamento al seno sull’accrescimento dei bambini allattati esclusivamente al seno per 6 mesi o oltre, le madri dei bambini allattati più a lungo hanno amenorree più prolungate. Vengono infine raccomandati ulteriori studi per puntualizzare i piccoli effetti sull’accrescimento riscontrati per confermare i benefici dell’allattamento esclusivo al seno per 6 mesi o oltre.

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Discussione: Voglio far notare che è vero che nessuno mette in discussione che il latte materno costituisca la migliore soluzione e opportunità per mamma e bambino, ma che comunque negli studi si fa sempre riferimento ad allattamenti di 6 mesi, aggiungendo “e oltre”. Quindi non esiste una posizione ben determinanta e univoca della comunità scientifica che oltre i 6 mesi si abbiano ulteriori miglioramenti. E addirittura esiste qualche evidenza di aumento di talune patologie, come la dermatite atopica in caso di allattamento prolungato. A conclusione di tutto quanto, non sembra del tutto aberrante che io possa avere le mie opinioni, che ripeto restano MIE opinioni e non mi sembra affatto di aver dato informazioni errate come mi è stato contestato.

In un’ottica di dialettica scientifica sono disponibile a continuare la discussione e ad avere anche ulteriori critiche, a condizione che non siano corredate di minacce legali o di altro tipo, che in verità tagliano qualsiasi strada alla invocata dialettica scientifica e cercano di instaurare un arrogante discorso unilaterale. Grazie.

Dott. Salvatore Annona

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