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American Journal erf Epidemiology Vol. 150, No.

Copyright O 1999 by The Johns Hopkins University School of Hygiene and PubOc Health Printed In USA
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In a recent study, Cushing et al. (1) found that breastfeed- other 12 family or social factors considered. Furthermore,
ing significantly reduced the duration but not the incidence of colds/snuffles/sneezing was the only one of 15 symptom
respiratory illness during the first 6 months of life, conclud- complexes that was statistically related to feeding mode. In
ing that breastfeeding reduces respiratory illness in infants. a study of singletons (10), there was a dose-response rela-
Inspection of their table 3 shows that they should have disag- tion between breastfeeding (fuU/partial/nil) and diarrhea,
gregated these illnesses. Lower respiratory illnesses were sig- pneumonia, otitis, colds, and fevers that was consistent with
nificantly less common in the fully breastfed, while upper res- the sompe mechanism. With siblings, where airborne dis-
piratory illnesses were more common in both the partially ease was likely, otitis, colds, and fevers were, in contrast,
breastfed and the fully breastfed. This excess would undoubt- most common in partially breastfed infants.
edly have been statistically significant had otitis media, which The finding in this second independent sample replicates
Cushing et al. did not ascertain, been excluded, since there is that in the original one (2): Sompe infections, but not non-
considerable evidence that otitis media is more common in sompe infections, are more common among the nonbreast-
the nonbreastfed. A wider literature review would have shown fed. Once again, colds are more common in the breastfed.
that opposite relations between breastfeeding and different This finding has been ignored, which is surprising; if cor-
types of respiratory illnesses are a) consistent with the previ- rect, it demolishes at a stroke alternative explanations for
ous literature (2), which no longer seems confusing and con- greater morbidity in the bottle-fed. Those explanations
tradictory; b) explicable by a mechanical theory for the pro- include the following:
duction of otitis media (3); and c) predicted to occur (2). In
fact, when I encountered their paper I had been checking the 1. Antiinfective substances in breast milk, which could
Journal for any infant feeding studies that addressed respira- explain varying organism infectivity but not infection
tory illness subtypes. sites.
I previously proposed (2) that the main cause of high 2. Increased exposure to infective agents, which could
infant mortality and morbidity is supine feeding, especially explain gastrointestinal susceptibility but not respira-
bottle propping, leading to the "sompe" syndrome. This tory illness susceptibility.
causes pooling of liquids in the middle ear, with secondary 3. Poorer overall nutrition, which should increase sus-
reflux down the eustachian tubes into the stomach and ceptibility to all infections.
lungs, causing gastroenteritis and pneumonia. Protective
factors in breast milk or pathogens in bottle milk are irrele-
vant. A clear prediction was that sompe infections consistent REFERENCES
with this mechanism would be more common in the bottle-
fed but that nonsompe infections, especially colds, would 1. Cushing AH, Samet JM, Lambert WE, et al. Breastfeeding
not be. My review confirmed this difference. Unexpectedly, reduces risk of respiratory illness in infants. Am J Epidemiol
while individual studies were equivocal, in toto they clearly 1998;147:863-70.
indicated that colds were more common in the breastfed. 2. Gordon AG. Respiratory and gastrointestinal infections and
(An ad hoc explanation is the proximity of the noses of prop feeding. (Letter). Int J Epidemiol 1986;15:138-9.
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after supine bottle feeding. J Pediatr 1995;126:S105-ll.
corollary is that the portal of entry for organisms causing 4. Gordon AG. Dirty habits. (Letter). Nature 1992;355:196.
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appeals, this theory also remains unchallenged (4). materna en un area rural de Nicaragua. (In Spanish). Rev
I have reviewed later papers on the relative incidence of Cubana Pediatr 1985;57:717-30.
sompe and nonsompe infections among the breastfed. In 6. Miskelly FG, Burr ML, Vaughan-Williams E, et al. Infant
rural Nicaragua (5), diarrhea and cough, but not colds or feeding and allergy. Arch Dis Child 1988;63:388-93.
fever in general, were found to be more common during the 7. Rubin DH, Leventhal JM, Krasilnikoff PA, et al. Relationship
between infant feeding and infectious illness: a prospective
previous week in infants with the least amount of breast- study of infants during the first year of life. Pediatrics 1990;
feeding. Diarrhea, but not nasal discharge, was significantly 85:464-71.
more common in nonbreastfed infants (6). In an affluent 8. Ford K, Labbok M. Breast-feeding and child health in the
Danish sample (7), upper respiratory illness was more com- United States. J Biosoc Sci 1993;25:187-94.
mon in the breastfed and gastroenteritis and otitis media in 9. Holme CO. Incidence and prevalence of non-specific symp-
the formula-fed; this difference appears to be significant but toms and behavioural changes in infants under the age of two
was untested by the authors. In a large US national survey years. Br J Gen Pract 1995;45:65-9.
(8), breastfed infants had significantly less pneumonia and 10. Raisler J, Alexander C, O'Campo P. Breast-feeding and infant
fewer ear infections or operations. There was no significant illness. Am J Public Health 1999;89:25-30.
relation with tonsillitis, but there was a hint that asthma and
allergies (including hay fever) were more common in the A. G. Gordon
breastfed. Holme (9) reported more upper respiratory symp- 32 Love Walk
toms in breastfed infants. This excess was not an artifact or London SE5 SAD
a result of confounding, since it was independent of the United Kingdom


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