LETTERS TO THE EDITOR
Breastfeeding and
Maternal Smoking
I wish to address the statement re-
garding maternal smoking and breast-
feeding. In your article, it states,
Maternal smoking is not an absolute
contraindication to breastfeeding but
should be strongly discouraged, be-
cause it is associated with an in-
creased incidence in infant respiratory
allergy. After this false information,
you have cited reference 102. I scrolled
down to the references to nd this
information and see that it was taken
from Pediatric Allergy and Immunology
2009;20(1):3034. However, the content
of this reference must have been
misunderstood. It states, Exposure to
maternal smoking in the rst year of
life interferes in breast-feeding pro-
tective effect against the onset of re-
spiratory allergy from birth to 5 yr.
This being true, it states nothing of the
fact that it increases incidence of in-
fant respiratory allergies but that it
lessens the protective effect against it.
A mother who is smoking while nurs-
ing, most likely was a mother who was
smoking while pregnant, which means
the baby has already been exposed
to nicotine. Encouraging a smoking
mother not to breastfeed can cause the
newborn to go through nicotine with-
drawal after birth. Also, the protective
effects in the mothers milk far out-
weigh the small amount of nicotine
that passes through the breast milk.
The infant is going to be exposed to
smoking in any case because of ma-
ternal use of cigarettes, and there-
fore the benets of breast milk to that
infant would actually prove more im-
portant than to an infant in a non-
smoking household. Please reconsider
the wording in your article. Many
physicians are already severely un-
informed regarding the benets of
continued breastfeeding, and giving
this false information to them only
PEDIATRICS Volume 130, Number 2, August 2012
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compounds the problem. Thank you for
your time and understanding.
Jennifer J. Phillips
Women, Infant, and Children (WIC) Breastfeeding
Peer Counselor
Central Michigan District Health Department
REFERENCES
1. Mohrbacher N. Breastfeeding Answers Made
Simple. Amarillo, TX: 2010:536540
2. Guedes, HTV, Souza, LSF. Exposure to maternal
smoking in the rst year of life interferes in
breast-feeding protective effect against the
onset of respiratory allergy from birth to 5 yr.
Pediatr Allergy Immunol. 2009;20(1):3034
doi:10.1542/peds.2012-1647A
Breastfeeding and
Atopic Dermatitis
I recently read the policy statement on
breastfeeding and found it disappoint-
ing. The 1997 (updated 2005) statement
was a well-researched, thorough doc-
ument that appeared to take all re-
search into account.
Concerning and breastfeeding and atopic
dermatitis, the new statement reads:
There is a protective effect of exclusive
breastfeeding for 3 to 4 months in re-
ducing the incidence of clinical asthma,
atopic dermatitis, and eczema by 27% in
a low-risk population and up to 42% in
infants with positive family history.
The studies cited are a 2007 ARHQ
report (Ip, Chung et al) on breastfeed-
ing, and a 2008 (Greer et al) analysis to
support its claim that breastfeeding
aids in prevention of eczema.
The 2007 AHRQ report (which cites no
studies on this subject published after
2002) concludes: Available evidence
from one well-performed systematic
review/meta-analysis on full term in-
fants in developed countries suggests
that exclusive breastfeeding for at
least 3 months was associated with
a reduction in the risk of atopic der-
matitis in those subjects with a family
history of atopy.1
The 2008 analysis (Greer et al, which
cites no research post 2005) on infant
feeding and allergic disease, made
these conclusions: In summary, for
infants at high risk of developing at-
opy, there is evidence that exclusive
breastfeeding for at least 4 months or
breastfeeding with supplements of
hydrolyzed infant formulas decreases
the risk of atopic dermatitis com-
pared with breastfeeding with sup-
plements of standard cow milk-based
formulas. On the basis of currently
available evidence, this is less likely to
apply to infants who are not at risk of
developing atopy, and exclusive breast-
feeding beyond 3 to 4 months does not
seem to lead to any additional benet
in the incidence of atopic eczema.2
I would like to know where the 27% and
42% numbers come from.
There have been at least 5 studies in
the past few years that have not found
breastfeeding protective for atopic
dermatitis, some of which nd an in-
crease with breastfeeding.37
The rest of this policy statement is not
much better. In Table 2, dose responses
for reductions in obesity, diabetes,
cancer, and asthma are given, when
recent research is mixed at best as to
whether breast milk is preventative.
I feel that this policy statement is
a poor example of an analysis of
available research and information. I
hope the American Academy of Pedi-
atrics will look at this report with
a critical eye and rework it, taking all
available research into account.
Anne C. Risch, RN
REFERENCES
1. Ip S, Chung M, Raman G, et al.; Tufts-New
England Medical Center Evidence-based Prac-
tice Center. Breastfeeding and maternal and
infant health outcomes in developed coun-
tries. Evid Rep Technol Assess (Full Rep). 2007;
April(153):1186
2. Greer FR, Sicherer SH, Burks AW; American
Academy of Pediatrics Committee on Nutrition;
e461
 American Academy of Pediatrics Section on
Allergy and Immunology. Effects of early
nutritional interventions on the development
of atopic disease in infants and children: the
role of maternal dietary restriction, breast-
feeding, timing of introduction of comple-
mentary foods, and hydrolyzed formulas.
Pediatrics. 2008;121(1):183191
3. Langan SM, Fewtrell M. Does breastfeeding
protect against the development of eczema?
Br J Dermatol. 2011;165(6):11571158
4. Snijders BEP, Thijs C, Kummeling I, Penders
J, van den Brandt PA. Breastfeeding and in-
fant eczema in the rst year of life in the
KOALA birth cohort study: a risk period-
specic analysis. Pediatrics 2007;119. Avail-
able at: www.pediatrics.org/cgi/content/full/
119/1/e137
5. Giwercman C, Halkjaer LB, Jensen SM,
Bnnelykke K, Lauritzen L, Bisgaard H. In-
creased risk of eczema but reduced risk of
early wheezy disorder from exclusive breast-
feeding in high-risk infants. J Allergy Clin
Immunol. 2010;125(4):866871
6. Sandini U, Kukkonen AK, Poussa T, Sandini L,
Savilahti E, Kuitunen M. Protective and risk
factors for allergic diseases in high-risk
children at the ages of two and ve years.
Int Archives Allergy Immunology. 2011;156
(3):339348
7. Miyake Y, Tanaka K, Sasaki S, et al; Osaka
Maternal and Child Health Study Group.
Breastfeeding and atopic eczema in Japanese
infants: The Osaka Maternal and Child Health
Study. Pediatr Allergy Immunol. 2009;20(3):
234241
doi:10.1542/peds.2012-1647B
Donor Human Milk for
Preterm Infants
The evidence appraisal in this revised
American Academy of Pediatrics policy
statement endorses the practice of
supporting mothers to express breast
milk for their preterm infants using
evidence-based interventions. The ch-
allenge is to ensure that these are
implemented consistently and broadly,
and especially to vulnerable and so-
cially disadvantaged women who are
less likely to provide expressed breast
milk. However, the statement recom-
mending that preterm infants should
receive Pasteurized donor human
milk, appropriately fortied if the
e462 LETTERS TO THE EDITOR
mothers own expressed breast milk
is unavailable is not supported fully
by the current evidence.1 Whether
donor human milk is the optimal
alternative when maternal milk is
not available requires consideration
of feasibility, costs, acceptability, and
the effect on other important clinical
outcomes, principally growth and de-
velopment.1 Although good-quality evi-
dence applicable to the modern context
of neonatal nutritional care is emerg-
ing,2 additional large, pragmatic ran-
domized controlled trials are needed
to provide more reliable and precise
estimates of effect size and to ex-
plore cost-effectiveness. I am con-
cerned that, without qualication,
the advice in this American Academy
of Pediatrics Policy Statement may
have the unintended consequence
of discouraging clinicians and ser-
vice users from developing and par-
ticipating in randomized controlled
trials to address the remaining
uncertainties.
William McGuire
University of York
REFERENCES
1. Quigley MA, Henderson G, Anthony MY,
McGuire W. Formula milk versus donor
breast milk for feeding preterm or low birth
weight infants. Cochrane Database Syst Rev.
2007;(4):CD002971
2. Sullivan S, Schanler RJ, Kim JH, et al. An
exclusively human milk-based diet is asso-
ciated with a lower rate of necrotizing en-
terocolitis than a diet of human milk and
bovine milk-based products. J Pediatr. 2010;
156(4):562567, e1
doi:10.1542/peds.2012-1647C
Policy Statements on
Breastfeeding and
Human Milk: Additional
Comments
The American Academy of Pediatrics
publishes periodical breastfeeding
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policy statements; the latest1 updated
previous recommendations and added
new topics. These statements have
long been a reference for clinical pe-
diatricians and public health profes-
sionals worldwide. Accustomed to the
breadth of research in these state-
ments and knowing their importance,
I felt the lack of 2 topics of current
interest to pediatricians and public
health workers: pollutants in breast
milk and interactions between of vac-
cines and breastfeeding.
POLLUTANTS IN BREAST MILK
Environmental pollutants and hazard-
ous substances have become part of
modern life as a result of widespread
use coupled with inadequately con-
trolled (or unenforced) environmental
policies. Because of their ubiquity, they
reach all forms of life, entering and
contaminating aquatic and terrestrial
food chains; at the top of the ladder, we
nd breastfed babies. Only under ex-
ceptional circumstances (such as after
accidents) does the occurrence of
environmental chemicals in breast
milk result in a recommendation to
avoid breastfeeding. Indeed, most
studies of background exposure sug-
gest that breastfeeding can counter
subtle adverse effects associated
with in utero maternal exposure to
neurotoxic 2 or endocrine-disruptor
substances. 3
Progress in analytical techniques has
boosted studies dealing with milk
composition of potentially harmful en-
vironmental contaminants. As a result,
studies have shown the presence of
(organic and inorganic) environmen-
tal pollutants in maternal blood and
breast milk, raising concerns for pre-
gnant and breastfeeding mothers.
However, statements issued to health
professionals and mothers have not
always considered the results that
may ensue. Geraghty et al4 reported
the negative impact of poor reporting
 Breastfeeding and Atopic Dermatitis
Anne C. Risch
Pediatrics 2012;130;e461
DOI: 10.1542/peds.2012-1647B
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2012 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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 Breastfeeding and Atopic Dermatitis
Anne C. Risch
Pediatrics 2012;130;e461
DOI: 10.1542/peds.2012-1647B

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/130/2/e461.2.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2012 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from by guest on March 29, 2017