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Health Protection and Health Care in Canada
Protecting the Health of Canadians and the Health Care System in Canada
A Submission to the Commission on the Future of Health Care in Canada
By the Infant Feeding Action Coalition (INFACT) Canada
February 13, 2002
Canadians view universal health care as a basic human right. This has been expressed not only by the Interim Romanow Report but has also been ratified by the Canadian government through United Nations Conventions expressing that right. By exercising this right Canadians have enjoyed an exceptional, world-class health care service in their quest for the best attainable health. It is the expectation that this right will remain a fundamental principle as our health care system evolves to meet the needs of Canadians.
INFACT Canada is pleased that the Interim Report notes that the social arguments for health care are not in question. We applaud the principle that the system must not negatively impact the poor or the vulnerable and that any restructuring of the system must reconcile with sustainability. And we are pleased that the Interim Report recognizes health promotion and prevention as one of the key approaches to addressing the challenges of Medicare.
In response to the approaches suggested by the Interim Report, it is the view of INFACT Canada:
INFACT Canada, a national non-governmental organization that works to protect infant and young child health as well as maternal well-being through the promotion and support of breastfeeding and optimal infant feeding practices, wishes to address the “challenges of medicare” from the standpoint of the “fourth school of thought” of “reorganized service delivery” as expressed in the Interim Report. We wish to focus on the integration of health promotion and disease prevention into the structures of “reorganized service delivery” from the perspective of infant and young child nutrition.
Early optimal nutrition and long term health benefits
It has long been recognized that early nutrition has a life long impact on the health of an individual. Substantial bodies of research, and an Expert Consultation of the World Health Organization, have both determined that exclusively breastfeeding an infant from birth with the addition of nutritious complementary foods at six months and continued breastfeeding to the age of two years or beyond, confers optimal nutrition for infants and young children. Additionally, such best-practice infant and young child nutrition practices confer benefits well beyond early childhood. Infants who are not breastfed and are artificially fed with infant formula substitutes experience increased risks of a wide range of both infectious and chronic illnesses. Some recent examples of population studies have determined that when children are breastfed they experience:
· Reduced risk of asthma and wheeze
Approximately five to 10 per cent of Canadian adults suffer from asthma. As many as 20 per cent of Canadian children have asthma.
Researchers at the Hospital for Sick Children, Toronto reported that the risk of asthma and wheezing was reduced by approximately 50 per cent when infants were breastfed for nine months or longer. The longer the duration of breastfeeding, the greater the protection against the development of asthma. The authors concluded that more public health efforts need to be directed toward increasing the initiation and duration of breastfeeding.
Dell, S. and To, T., Breastfeeding and Asthma in Young Children. Arch Pediatr Adolesc Med 155: 1261-1265, 2001
· Reduced risk of infectious disease
Acute respiratory disease during infancy hospitalized 22036 infants in 1999.
A British, 7 year follow-up study, of 545 children determined that the “probability of respiratory illness occurring at any time during childhood is significantly reduced if the child is fed exclusively breastmilk for 15 weeks and no solid foods are introduced during this time. Breastfeeding and the late introduction of solids may have a beneficial effect on childhood health and subsequent adult disease”. Additionally the study determined that exclusive breastfeeding for 15 weeks reduced the probability of wheezing, and also that systolic blood pressure was raised significantly in children who were exclusively bottlefed.
Wilson, A.C. et al. Relationship of infant diet to childhood health: seven year follow up of cohort of children in Dundee infant feeding study. BMJ 316: 21-25, 1998
Cardiovascular disease is the leading cause of death of over one-third of Canadians. About 26 percent of men and 18 per cent of women are reported to have high blood pressure.
Researchers from Great Ormond Street Hospital, London, UK, measured blood pressure at age 13-16 years in 216 (23%) of a group of 926 children who were born prematurely. For the follow up at ages 13 and 16 years systolic, diastolic and mean arterial blood pressure were recorded. At the age of 13 and 16 mean arterial pressure in children assigned banked breastmilk and preterm formula was significantly lower. Blood pressure measurements were lower in infants fed banked breastmilk than in those fed preterm formulas after adjustment for sex, mean daily enteral sodium intake in infancy, and current body-mass index.
The investigators conclude that breastmilk consumption in children born prematurely was associated with lower blood pressure in later life. The authors concluded that the data are also applicable to populations born at term as blood pressure in the adolescent population was not related to birth weight for gestational age nor affected by pubertal growth spurt.
Importantly this research "indicates (the) adverse affects of formula feeding on CVD risk factors, which is consistent with the observations of increased mortality among older adults who were fed formula as infants".
Singhal A, Cole TJ, Lucas A. Early nutrition in preterm infants and later blood pressure: two cohorts after randomised trials. The Lancet 357: 413-419, 2001
· Reduced risk of obesity
Approximately 29 per cent of the adult Canadian population is obese and more than 50 per cent are overweight. Breastfeeding significantly reduces the likelihood of overweight and obesity and its associated health risks.
In the order of 15,000 young adolescents between the ages of nine to 14 years were analyzed for risk of obesity and overweight in a US based Harvard Medical School study. Mothers reported on the duration of breastfeeding, the exclusivity of breastfeeding and when solids were first introduced. During the first six months of life, 62 per cent of the subjects had been only or mostly breastfed and 31 per cent were mostly fed infant formulas. At ages nine to 14, the children who were almost exclusively breastfed for the first six months were 22 per cent less likely to become overweight as adolescents.
The authors also reported a dose dependent effect -- those who had been breastfed for at least seven months had a lower risk than those who reported breastfeeding for three months or less. Although this study did not determine a direct link between breastfeeding and the reduced risk for obesity, they did postulate that the higher levels of insulin in formula fed babies could explain the higher accumulation of fat. Also, bottle fed infants have less ability to self regulate the amount of formula consumed.
Gillman, M. W. et al Risk of overweight among adolescents who were breastfed as infants. JAMA 285: 2461-2467, 2001
· Reduced risk of diabetes
Both adult onset diabetes (Type 2) and juvenile onset diabetes (Type 1) are influenced by infant and young child nutrition. The prevalence of physician diagnosed diabetes in Canada is about 3 per cent of the total population over 15 years of age. The rates among Native and Inuit populations is about 3.3 times higher for men and 5.5 times higher for women.
Breastfeeding reduces both the incidence of Type 1 and Type 2 diabetes as well as the risk factor of obesity
Observations linking early exposure to cow's milk formula proteins to the development of Type 1 diabetes (juvenile-onset) have been reported in the scientific literature for some time. Researchers from Finland have now confirmed that early oral exposure to cow's milk protein induces an insulin immune response. In diabetes-prone children this can bring about autoimmune pancreatic beta cell destruction. Type 1 diabetes is known to be the result of the destruction of pancreatic beta cells and the immunization to insulin plays a key role in the autoimmune destructive course leading to pancreatic cell loss.
This study compared 100 infants who were exposed to cow's milk formula before the age of 12 weeks and 100 infants who were exclusively breastfed for longer than their first 12 weeks. The amount of IgG-antibodies binding to bovine insulin higher was higher at 3 months for babies exposed to cow's milk formula than in infants who were exclusively breastfed. The antibodies binding to bovine insulin also reacted with human insulin.
From this the authors conclude that primary immunization to insulin is induced in infancy by oral exposure to cow's milk insulin, indicating sensitization to insulin in non-diabetic children. The possibility that insulin-specific lymphocytes induced by cow's milk feeding may be activated in some children needs to be considered as a possibly mechanism leading to autoimmune destruction of beta cells and subsequent progression to clinical type 1 diabetes.
Dr Hans-Michael Dosch from the Hospital for Sick Children, Toronto, commenting on the research noted, "evidence against cow's milk is piling up". He cited the example of Puerto Rico where fewer than 5 per cent of mothers breastfeed and the majority use cow's milk based formulas. Meanwhile type 1 diabetes is 10 times the rate as seen in Cuba where breastfeeding is nearly universal.
Vaarala, O et al. Cow's Milk Formula Feeding Induces Primary Immunization to Insulin in Infants at GeneticRisk for Type 1 Diabetes, Diabetes 48:1389-1394, 1999
· Reduced risk of Sudden Infant Death
The number of SIDS deaths has fallen steadily since the late 1980s – from 385 in 1989 to 138 in 1999. Recommended strategies for reducing the incidence – supine sleeping position, no smoking and breastfeeding – are considered to be contributing to the reduced incidence.
Infants that died suddenly were studied as part of a European Concerted Action on SIDS. Three pediatric pathologists classified 63 cases into three groups: SIDS (19 cases), borderline SIDS (30 cases) and non-SIDS (14 cases). The distribution of the epidemiological risk factors was determined for the three groups. This Dutch study found that non-SIDS cases had received more breastfeeding, parents hardly smoked during pregnancy and after birth and a firm mattress had been used. Borderline SIDS was associated with previous hospital admission, low birth weight and/or short gestation. The SIDS cases were associated with lower socioeconomic status, maternal smoking after birth, bottlefeeding and thumb sucking. The authors propose that all categories of sudden death be analyzed with the objective of developing recommendations for prevention.
Hoir, M.P. et al Sudden unexpected death in infancy: epidemiologically determined risk factors related to pathological classification. Acta Pediatr 87: 1279-1287, 1998
The loss of even one IQ point per person spread over a population has vast economic consequences for a nation.
A British follow-up study of premature infants reports the intelligence quotients results of 8 year olds who had been fed their own mother’s milk after birth. The children who had received their mother’s milk had a significantly higher IQ at ages 7.5 to 8 years than children who did not receive breastmilk. After adjusting for differences between the two groups, the study children had an 8.3 point advantage in IQ scores. Interestingly, this difference was not attributed to the interaction between the mother and infant because the infants had been fed by nasogastric tube.
Also the researchers were able to show a dose relationship between the amount of breastmilk fed and the subsequent IQ outcomes. They concluded that breastmilk itself conferred substantial advantages for cognitive development and that this could perhaps be explained by the presence of various factors in breastmilk necessary for the development of neural tissue such as long chain fatty acids which are completely missing in infant formulas. (DHA is uniquely high in the mother’s milk of a premature infant.)
Lucas, A. et al
Breast milk and subsequent intelligence quotient in children born premature.
A New Zealand longitudinal study examines the association between the duration of breastfeeding, childhood cognitive ability and academic achievement from the ages of 8 to 18 years. Data was collected on breastfeeding practices from birth to 1 year and between 8 and 18 years on such things as IQ, teacher ratings of school performance, reading comprehension and math tests, and pass rates in school exams.
Results demonstrated increased duration of breastfeeding was associated with statistically significant increases in IQ assessed at the ages of 8 and 9; reading comprehension and math ability assessed at ages 10 to 13; teacher ratings of math and reading assessed at ages 8 and 12; and higher levels attained in school leaving exams.
The authors concluded that breastfeeding is associated with a small but detectable increase in child cognitive ability and educational achievement and that these effects are broad and extend into childhood and early adulthood.
Horwood, L.J. and Ferguson, D.M Breastfeeding and later cognitive development and academic outcomes. Abstract. Pediatrics, 101(1) 99. 1998
Early optimal nutrition and economic benefits
Early optimal childhood nutrition confers significant and life long health benefits. Such benefits contribute significantly not only to individual well-being, but also to the well being of families, society and provide great economic benefit to the health care system. Although these cost benefits - reduced risk of infectious and chronic disease - are difficult to quantify, hospitalization rates for common childhood ailments will give some information towards the enormous cost savings that can be achieved. Adequate surveillance data is not available to adequately translate these health benefits into economic benefits of cost savings; nevertheless estimates can be made to highlight the enormous potential of economic savings. INFACT Canada has estimated the hospitalization cost of not breastfeeding in a number of areas:
1. These costs reflect only the cost of hospitalization. Additional costs are incurred at all other levels of the health care system, as well as the cost of chronic care over the lifetime of that individual.
2. Battlefords (Sask) Health District monitors pediatric admission per diagnosis and mode of infant feeding. They reported in 2000 that 80 per cent of pediatric admissions were not breastfeeding at time of admission, 17 per cent were breast and bottlefed and only 3 per cent were breastfeeding.
3. Total health care costs in Canada for 2000: $95 billion of which (31.8%) is considered hospital costs.
Breastfeeding in Canada
Percentage of children less than two years of age ever breastfed in Canada is estimated to be 73.
A more detailed analysis is available from the Ontario Mother and Infant Survey: Breastfeeding rates varied amongst centers with the lowest initiation rates (82%) and the lowest continuation rates (76%) in northern, more remote communities. These communities also had the highest proportion of low-income and non-partnered women. Where women had access to a large urban teaching hospital setting, initiation rates (96%) and breastfeeding continuation at 4 weeks (77%) were highest.
Declines in breastfeeding within the first 4 weeks ranged from 13 to 24 % with the majority switching to artificial feeding within the first 7 days (40 to 63%).
In conclusion the reports highlights the need for early support and help during the first 2 weeks. As well interventions for vulnerable women are needed to address their special needs.
Sheehan, D. et al. The Ontario Mother and Infant Survey: Breastfeeding Outcomes. J Hum Lact 17:211-219, 2001
Some provinces have now initiated post partum visits during the first two weeks after discharge. However such access to breastfeeding help is not universally available across Canada.
Support for and recognition of the vital contributions that breastfeeding women make to the health care system and to the well being of Canadian society is grossly undervalued.
Low cost initiatives and high benefit interventions
Approximately 400,000 infant and mother pairs (800,000 mother and babies) are directly impacted by Canada’s infant and young child nutrition policies annually.
Societal support for optimal infant and young child nutrition as practiced through exclusive breastfeeding and continued breastfeeding to two years and beyond, is an exceptionally low-cost health promotion initiative.
Breastfeeding as a normal infant feeding practice requires no expensive technological inputs; no drugs are requires; no equipment is required; no institutionalization is required; no medical laboratories are required, yet the benefits derived are massive. Breastfeeding is free. As a nutritional and immunological fluid it has unique and irreproducible qualities. No drug or device can come even close to the life giving qualities of breastmilk. Breastfeeding as a bonding action between a mother and her infant provides love and emotional security.
As noted above, Canadian mothers still fall far short of achieving optimal infant feeding practices. Surveys monitoring infant and young child nutrition practices indicate that Canadian mothers do not even come close to the recommendations as set by the World Health Organization. Improving breastfeeding support structures so that all mothers and infants are enabled to fully practice optimal infant feeding can be achieved. In countries such as Brazil where regulatory measures, promotional programs and full institutional support for breastfeeding have been put into place, the initiation and duration of breastfeeding has risen sharply.
Many barriers from societal resistance to lack of adequate support to commercial interference by the infant formula companies exist. A number of these barriers can be removed by inexpensive policy and regulatory measures.
Low cost measures are all that is needed to improve societal support for breastfeeding practices. Such support needs to be derived from various sectors of society – the work place, the community and the health care system. The reform of Canada’s maternity benefits legislation is a major step in providing needed support.
What Canada’s government can do
A number of key support structures can be put in place to strengthen the Interim Report’s “fourth school of thought” of “reorganized service delivery”.
Statistical Data from:
The Canadian Institute for Health Information
The Changing Face of Heart disease and Stroke in Canada, 2000
Perinatal Health Indicators for Canada, Health Canada, 2000