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The importance of breast milk in protecting the newborn from lymphocytes, plasma cells, immunoglobulins, and anti-
infection is recognized worldwide. Infant morbidity and mortality bodies. Cell-mediated immunity refers to the reaction of
have been directly affected by a decline in breastfeeding. Health sensitized T lymphocytes and the interaction with mac-
care providers are working toward meeting the national goal of rophages.
increased initiation and duration of breastfeeding. This article
focuses on the protective factors transferred to the infant through
breast milk. A discussion of maximizing the immunologicbenefits of Transfer oflmmunity
breast milk for the high-risk infant is presented.
Passive immunity results from active placental transfer of
specific antibodies from mother to fetus. Most IgG
transfer occurs during the 3rd trimester and increases
with increasing gestational age. IgG antibodies to viruses
and bacterial toxins provide transient protection to the
newborn. Antibody protection against the encapsulated
here is no substitute for breast milk. Commercial pyogenic organisms such as Streptococcus, Hemophilus
formulas may meet the nutritional needs of prema- injuenzae, Staphylococcus, and Pneumococcus is pres-
ture and term infants; however, the protective properties ent for the first several months of life. There is limited or
of breast milk are unique and cannot be duplicated in the no transfer of antibodies to agents that produce IgA or
laboratory. The components identified in breast milk are IgM antibody response. This places the newborn at high
multifunctional and interactive. The composition of risk for infection caused by gram-negative organisms
breast milk complements the developing host defense such as Escherichiu coli, Salmonella, and Shigella. In ad-
system in the newborn infant. dition, the infant cannot be protected against organisms
to which the mother has little or no immunity.
Table 1. Major Host Defense Factors in Colostrum and Fresh cells and secrete antibodies. Maternal exposure to the in-
Human Milk fants microorganisms results in the production of milk
antibodies, which in turn protect the breastfed infant.
Immunoglobulins Breastfeeding protects against upper respiratory in-
Secretory IgA fection, specifically against respiratory syncytial virus
(Laegreid, Kolstbotnaess, Brstavik, & Carlsen, 1986). Se-
IgM cretory IgA binds to mucosal epithelium and inhibits bac-
IgG terial or viral adherence to mucosal cells. Protection of
Lactoferrin the respiratory tract may be linked to regurgitation of
Lysozyme milk into upper airways (Hayward, 1983). Secretory IgA
Complement proteins antibody protects by neutralizing enterotoxins (Stoliar,
Bifidus factor Pelley, Kaniecki-Green, Klaus, & Carpenter, 1976). This
effect may explain why infants with diarrhea caused by
Cellular components certain strains of E. coli show improvement when fed
Macrophages breast milk.
T and B lymphocytes
Polymorphornuclear leukocytes (PMN) IgM and IgG
The level of IgM is highest in colostrum and decreases
during the first week of lactation. The IgG concentration
is constant during the first 6 months of lactation (Ogra
cocci also are present in breast milk. The immune factors & Ogra, 1978). IgM and IgG bind complement. Bacteria
in breast milk have shared features: coated with these antibodies can be opsonized for phago-
cytosis.
1. they are common to mucosal sites;
2. they are capable of surviving in the gastrointestinal
tract because they are resistant to digestive Lactoferrin
enzymes; Lactoferrin is an iron-binding protein that functions in a
3. they kill certain bacterial pathogens synergistically; bacteriostatic manner by depriving organisms of iron.
4 . their protection is achieved without triggering Lactoferrin also acts on microbes by blocking carbohy-
inflammatory reactions; and drate metabolism, attacking the cell wall, and binding
5 . the secretion of many soluble immune factors by the calcium and magnesium (Sanchez, Calvo, & Brock,
mammary gland is inversely related to the ability of 1992). Organisms with high iron requirements, such as
the recipient to produce them at mucosal sites
(Goldman, 1993).
Table 2. Organsisms Affected by Anti-infective Factors in
Human Milk
Secretory IgA
The most abundant immunoglobulin present in breast
Bacterta Vtruses
milk is secretory IgA.The secretory component enables
the IgA molecule to resist digestion by pepsin and trypsin Escbericbia coli Rotavirus
and hydrolysis by gastric acid. The concentration of IgA
Salmonella Rubella
is highest in colostrum and peaks during the first 3-4
postpartum days. As the volume of milk increases, the Sbigella species Poliovirus 1 , 2 , 3
concentration of IgA declines and reaches a plateau that Vtbriocbolerae Echovirus
remains higher than maternal serum levels during lacta- Bacteriodesfragtllis Coxsackie viruses A and B
tion (Ogra & Ogra, 1978). Bordetella pertussis Respiratory syncytial virus
Secretory IgA found in breast milk protects the infant Clostridium tetani Cytomegalovirus
from a variety of enteric and respiratory pathogens. Anti-
Clostridium dijicile Influenza A virus
bodies to bacteria, viruses, parasites, and fungi have been
identified in breast milk (Table 2). Most of the antibodies Corynebacterium diptbertae Arboviruses
present in breast milk are directed against organisms that Streptococcus mutans Herpes simplex type 1
colonize or are pathogenic to the gastrointestinal and Streptococcuspneumoniae Other
respiratory tracts. The unique antibody composition of Haemopbiluspertussis Candtda albicans
breast milk compensates for the lack of protection against Giardia lamblia
Diplococcuspneumonae
enteric antigens in placentally transferred IgG. Transfer
of antibodies via breast milk is specific for pathogens Staphylococcus aureus Entamoeba bistolytlca
present in the mothers environment. Sensitized lympho- Haemopbilus tnpuenza type B
cytes are transported from the maternal gastrointestinal Mycobacterium tuberculosis
and bronchotracheal-associated lymphatic tissues to the Chlamydia tracbomatis
mammary gland, where they differentiate into plasma
herpes simplex, hepatitis B and CMV. The greatest risk there is no absorption of secretory IgA antibodies and
for severe CMV infection is in the premature infant of a other proteins of proven benefit to the infant (Hopkin-
nonimmune mother who has no serum antibody to CMV. son, Garza, & Asquith, 1990).
Donor screening for CMV or pasteurization of donor milk Refrigeration of breast milk protects cell viability and
should be done to avoid transmission of the virus to the function. A significant loss of cellular viability is noted
nonimmune infant (Goldfarb, 1993). when breast milk is stored at 4 C for more than 48 hours.
Human immunodeficiency virus (HIV) has been iso- Guidelines on the recommended storage time for refrig-
lated from the breast milk of infected women. The Cen- erated breast milk vary. Refrigeration times that exceed
ters for Disease Control and the Public Health Service 48 hours result in approximately 50% reduction of viable
recommend that women in the United States who test and functional cells (Pittard & Bill, 1981). Based on re-
positive for HIV should not breastfeed. This will avoid search findings, a more stringent protocol for high-risk
postnatal transmission to the infant, who may not be in- infants in the hospital is required to provide maximal pro-
fected (Lawrence, 1994). Death rates in developing tective properties. The Committee on Nutrition of the
countries among infants not breastfed far exceed the risks American Academy of Pediatrics and the Canadian Pedi-
of HIV transmission by this route. The World Health Or- atric Society recommend that milk be stored at 3-4C if
ganization has recommended that unless safe infant for- it can be used within 48 hours and at -20C or lower for
mulas are readily available, breastfeeding should con- longer storage (Goldfarb, 1993).
tinue to be promoted, even in areas where the HIV epi-
demic is most severe (Goldfarb, 1993).
Methods of collection and storage of expressed
breast milk may alter the available protective factors. Ide-
ally, fresh breast milk should be expressed before each Freezing breast milk significantly alters its
feeding. This method maximizes the anti-infective prop- cellular stability, but there is only minimal
erties of breast milk received by the compromised infant. effect on its antibody content.
The need for refrigeration and freezing is eliminated.
However, most mothers are unable to remain near their
infants in the hospital for extended periods of time. Many
premature and ill infants are unable to consume a large
volume of milk. Refrigeration and freezing of expressed Freezing breast milk significantly alters its cellular
milk are needed for these infants. stability, but there is only minimal effect on its antibody
Bacteria found in breast milk when collected under content. No viable cells remain in breast milk after freez-
strict conditions usually reflect normal skin flora. Con- ing. Samples that were subjected to deep freezing at
centrations of normal flora in refrigerated milk samples -20C for 3 months had no significant decrease in lacto-
decrease with time. The bacterial inhibitory factors in ferrin, lysozyme, IgA, IgG, and C3 (Evans, Ryley, Neale,
breast milk remain active during refrigeration and freez- Dodge & Lewarne, 1978). Bacterial growth-inhibiting ac-
ing (Hernandez, Lemons, Lemons, & Todd, 1979; Sosa & tivity remains present in milk samples frozen for as long
Barness, 1987). It appears that factors involved in sup- as 3 weeks (Hernandez et al., 1979).
pressing bacterial growth are heat labile because pasteur- Methods of thawing frozen breast milk can adversely
ization destroys bacterial inhibition properties in breast affect the anti-infective factors. Use of microwave ovens
milk. to thaw frozen breast milk or to warm freshly expressed,
Anti-infective properties of breast milk are affected refrigerated milk can be detrimental. The greatest effect
by the type of container used for storage. Glass, polyeth- is seen at high temperatures. A marked decrease in activ-
ylene bags, and rigid polyethylene containers are com- ity of anti-infective factors was noted when samples were
monly used to store breast milk. Nylon-laminated bags subjected to microwave temperatures of 72-98C. Warm-
also have been introduced. Early research in breast milk ing in the microwave at low temperatures (20-53C) re-
banking reported decreased leukocyte counts in milk sulted in significant decreases in lysozyme and specific
stored in glass containers (Paxson & Cress, 1979). Later IgA to E. coli serotype 06. When temperatures were con-
studies reported cell count to be affected more by storage trolled at 20-25"C, the growth of E. coli was five times
length than by type of container (Goldblum, Garza, John- greater than the control sample (Quan et al., 1992). For
son, Nichols, & Goldman, 1981). Because live cells are optimal benefit, frozen milk should be thawed in the re-
destroyed by freezing, the effect of container type on the frigerator and used for feeding within 24 hours. Contam-
remaining immune properties becomes critical. Storing ination can occur during warming when milk containers
breast milk in polyethylene bags dramatically reduces are submerged in warm tap water. Slow warming at a
the amount of secretory IgA antibodies. Difficulty in fill- steady temperature can be accomplished in the hospital
ing and handling the bags increases the risk of contami- using a standard laboratory incubator (McCoy, Kadowaki,
nation. Rigid polypropylene plastic containers maintain Wilks, Engstrom, & Meier, 1988).
the stability of cells and immunoglobulins (Goldblum, The use of breast milk as prophylaxis against infec-
Goldman, Garza, Johnson, & Nichols, 1982). Glass con- tion is optimized when the infant is allowed to feed di-
tainers are the best choice for storing breast milk because rectly at the breast. Specific protocols aimed at maximiz-
ing t h e i m m u n o l o g i c benefits of breast milk s h o u l d be (1986). Neutralizing activity in human milk fractions
used for t h e high-risk infant. Mothers s h o u l d receive de- against respiratory syncytial virus. Acta Paediatrica Scan-
tailed instruction i n proper t e c h n i q u e s of p u m p i n g and dinavia, 75,696-701.
storing milk. The i m p o r t a n c e of fresh colostrum for early Lawrence, R. A. (1994). Host-resistance factors and immuno-
logic significance of human milk. In R. A. Lawrence (Ed.),
feeding s h o u l d be emphasized. Routine bacteriologic
Breastfeeding: A guide for the medical profession, 4th ed.
surveillance of e x p r e s s e d breast milk assures no patho- (pp. 149-180). St. Louis: Mosby.
gens are transmitted t o t h e high-risk infant via breast Losonsky, G. A., & Ogra, P. (1992). Immunology of the breast
milk. Protocols for c o n t i n u o u s f e e d i n g of breast milk and host immunity. In R. A. Polin & W. W. Fox, Fetal a n d
s h o u l d address f r e q u e n t change of syringe and t u b i n g t o neonatal physiology (pp. 1481-1488). Philadelphia: WB
prevent bacterial overgrowth. Intermittent gavage feed- Saunders.
ing of fresh breast m i l k should be used when possible. Lucas, A., &Cole, T. (1990). Breast milk and necrotizing entero-
Neonatal intensive c a r e unit protocols that provide a colitis. The Lancet, 336, 1519-1523.
comprehensive approach t o breastfeeding s u p p o r t for McCoy, R., Kadowaki, C., Wilks, S., Engstrom, J., & Meier, P.
t h e p r e t e r m infant are essential. Early transition t o (1988). Nursing management of breastfeeding for preterm
infants. Journal of Perinatal Neonatal Nursing, 2(1), 42-
breastfeeding with t h e availability of e x p e r i e n c e d n u r s e s
55.
t o provide o n g o i n g s u p p o r t and consultation are k e y i n Meier, P., Engstrom, J. L., Mangurten, H. M., Estrada, E., Zim-
preventing breastfeeding failure (Meier e t al., 1992). merman, B., & Kopparthi, R. (1992). Breastfeeding support
services in the neonatal intensive-care unit. JOGNN, 22(4)
338-347.
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