This was in response to this:

http://www.lactivist.net/?p=1608

6^th September 2010

Ref – Complaint about article in Mother and Baby Magazine July 2010.

Dear William.

Thank you for forwarding the reply from Mother and Baby.  I want to start by clarify my reasons for complaining about the article ‘I formula feed so what” by Kathryn Blundell.

I specifically complained under the Accuracy clause of the Code about these quotes taken from the article:

1.      “supposed health benefits [of breastmilk]”

2.      “I also wanted to give my boobs at least a chance to stay on my chest rather than dangling around on my stomach”

3.      “felt like getting tipsy once in awhile”

I strongly believe that the press has a duty of care to present accurate facts in relation to breastfeeding, especially when the publication in question is specifically aimed at pregnant and new mothers who can be influenced. Given that the World Health Organisation recently found that not breastfeeding results in the loss of 1.5 million babies, globally, every year and costs the economy billions in sick days, health bills and so on – it is clear that breastmilk alternatives are bad for a baby’s health and any suggestion to the contrary is not only misleading but dangerous.

This is not a campaign against personal opinion, this is a campaign against inaccurate and dangerous information being printed in an influential magazine with a vulnerable target audience.

I’ve copied the response from Mother and Baby and to make sure I don’t miss anything I’ll respond to it below.

July 14^th 2010

Dear William

Thank you for your letter of 1 July detailing two complaints received at the PCC.

Both complaints are reacting to a one-page opinion feature by Deputy Editor Kathryn Blundell in our July issue who – for reasons explained in the piece – decided to go straight to bottle-feeding. It was her choice, and this was an account of her personal experience, which the feature made abundantly clear. Readers could choose whether or not they agreed with Kathryn, and it is clear that a few vocal individuals, including the two complainants, strongly disagreed with Kathryn’s choice and her reasoning. But we defend our right to publish that opinion, and defend Kathryn’s right to express it has her ‘Viewpoint’.

Context is very important too. Mother and Baby promotes breastfeeding as the norm. Last summer we featured a cover of a model breastfeeding her baby, a first for the UK magazine industry.

The Green Parent which has a readership of 150000 per issue (http://www.thegreenparent.co.uk/downloads/TGP_Mediakit_2010.pdf) had a picture of a mother breastfeeding on the front cover of their April/May edition in 2008 so Mother and Baby were not first in the UK magazine industry.

We also conducted a campaign “Let’s Make Britain Breastfeeding Friendly” and we went on GMTV to back this up. I personally wrote a piece in the Daily Mail saying how outrageous it was that women are often made to feel uncomfortable. We offer help and advice to women on a monthly basis on this very issue: our May edition included a six page ‘get started and stick with it’ feature, our July issue (the one complained of) had a feature on the best breast pumps, and our next issue carries expert advice on surviving painful feeding in the early days.

Further, in the feature Kathryn herself states “Sure breast milk has the edge over infant formula – it’s free, it doesn’t need heating up and you can whip up a feed in the middle of the night without having to get out of bed. Then there are all the studies that show it reduces the risk of breast cancer for you, and stomach upsets and allergies for your baby.” Read as a whole, and in proper context, I do not think that anyone should reasonably have concluded that Mother and Baby were saying that breast was not best.

It is correct that Ms. Blundell’s article contained the following: “Then there are studies that show it reduces the risk of breast cancer for you, and stomach upsets and allergies for your baby” however, directly following this (and within the same paragraph) Ms. Blundell goes on to say ” But even the convenience and supposed health benefits of breastmilk couldn’t induce me to stick my nipple into a bawling baby’s mouth”. Supposed is not a word one would use to describe what is an inalienable truth.

Quoting from the Mother and Baby article again it says “Then there are all the studies that show it (breastfeeding) reduces the risk of breast cancer for you, and stomach upsets and allergies for your baby.” Either Mother and Baby don’t check their own facts  or they are by their own admission agreeing that formula feeding is bad for babies.

If these complaints are to be considered further, and by default Kathryn’s piece is not considered simply as an opinion piece, we would be obliged to ask for the opinion of medical professionals. For example, we would need to look at whether the research Miss Cole refers to on ‘breast sagginess’ was peer reviewed and published, and how the opinion and conclusion of those doctors sits with the general body of medical opinion.

I have put the expanded version of this research at the end of this document on page 6 of this letter. To get the full research you need to subscribe but I imagine that large publications have researchers who are able to do that.

The Effect of Breastfeeding on Breast Aesthetics

Research by Brian Rinker, MD, Division of Plastic Surgery, University of Kentucky,

Conclusions The risk of breast ptosis increases with each pregnancy, but breastfeeding does not seem to worsen these effects. Expectant mothers should be reassured that breastfeeding does not appear to have an adverse effect upon breast appearance.

The article in Mother and Baby inaccurately stated that breastfeeding makes breasts sag and that statement can influence a mothers’ decision to breastfeed. To illustrate the power of the press here I’d like to draw your attention to a recent poll by www.BabyChild.org.uk in which 1228 women between the ages of 18 and 25 were questioned. It found that 32% would not breastfeed because they wanted to avoid saggy breasts.  Half of the women polled had no plans to breastfeed. Half of them were afraid of their partner finding them less attractive should this happen. Another 19% felt ‘uncomfortable’ about the thought of breastfeeding, a quarter of whom said they viewed their breasts as sexual and therefore deemed it inappropriate.

Similarly, we would need medical opinion on the ‘extensive evidence’ on the risks of formula feeding that Miss Cole again refers to, and to understand how that research fits with the general body of medical opinion and research to the contrary.

The quote from the article in Mother and Baby written by Kathryn Blundell is “Formula milk is not toxic, lacking in nutrients or in any way bad for a baby’s health”

The World Health Organisation say this about breastfeeding

“Over the past decades, evidence for the health advantages of breastfeeding and recommendations for practice have continued to increase. WHO can now say with full confidence that breastfeeding reduces child mortality and has health benefits that extend into adulthood” http://www.who.int/child_adolescent_health/topics/prevention_care/child/nutrition/breastfeeding/en/

This research is about the risks of infant formula and the full version is on page 7:

What are the Risks Associated with Formula Feeding? A Re-Analysis and Review

McNiel, M. E., Labbok, M. H. and Abrahams, S. W. (2010), Birth, 37: 50–58. doi: 10.1111/j.1523-536X.2009.00378.x

Conclusions: Exclusive breastfeeding is an optimal practice, compared with which other infant feeding practices carry risks.

There are more studies on the risks of formula feeding that I can find if you need to see them.

We would also need to have opinion on whether it would be possible to feel tipsy (as opposed to drinking one unit of alcohol) and safely breastfeed. Our view is that it is not be appropriate to ask the PCC to adjudicate on matters of opinion such as these.

I don’t think any responsible mother would want to feel tipsy around a child no matter what they chose to feed them and I am sure Mother and Baby is not suggesting that in the article. My point was that it is safe to drink occasionally and still breastfeed.

Drug and Lactation Database – Alcohol – full research on page 29
CASRN: 64-17-5

http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~Fbz8ff:1

Casual use of alcohol (such as 1 glass of wine or beer per day) is unlikely to cause either short- or long-term problems in the nursing infant, especially if the mother waits 2 to 2.5 hours per drink before nursing, and does not appear to affect breastfeeding duration.

Thomas Hale on Breastfeeding – see page 38 for expanded version.
Thomas W. Hale, R.Ph. Ph.D., member of the La Leche League International Health Advisory Council, Medications and Mothers’ Milk (12th ed.):

Adult metabolism of alcohol is approximately 1 ounce in 3 hours, so mothers who ingest alcohol in moderate amounts can generally return to breastfeeding as soon as they feel neurologically normal. Chronic or heavy consumers of alcohol should not breastfeed.

You should be aware that we have been inundated by supportive emails and letters of Kathryn’s ‘Viewpoint’ article (43 in total which we are happy to make available in anonymous form for the PCC to see) applauding her honesty: in their opinion we have made readers feel ‘normal’ and less of a ‘failure’ for not managing to breastfeed – a situation which is incredibly common.

The Facebook group ‘Mother and Baby please support Breastfeeding’ has over 1,600 members including breastfeeding and formula feeding mothers. Please feel free to look at it and read the comments from the public on there. Nothing on there is anonymous.

http://www.facebook.com/?ref=home#!/pages/Mother-and-Baby-Magazine-please-support-breastfeeding/126495294055317?v=wall

Please do call me if you would like to discuss any of this further, and I am sure you will let me know if you wish me to expand on anything.

Yours sincerely

Miranda Levy

Editor

Mother and Baby

To conclude I’d like to express my surprise that a large publication such as Mother and Baby is happy to publish opinion that could persuade new mothers to feed their babies in a way that could be harmful to their health and I am further shocked that I (as a member of the general public) have been asked to find research to substantiate my claims when Mother and Baby (who I assume have a paid researcher if not a research department) have been able to print dangerously influencing untruths under the guise of opinion.

Many thanks for your time and patience over this matter.

Lisa Cole

The Effect of Breastfeeding on Breast Aesthetics

http://aes.sagepub.com/content/28/5/534.abstract?sid=2457d6c6-7633-486f-8dda-9e3e0545cdfa

1. Brian Rinker, MD^∗,
2. Melissa Veneracion, MD and
3. Catherine P. Walsh, MD

Author Affiliations

1. From the Division of Plastic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY

1. ∗ Brian Rinker, MD, Division of Plastic Surgery, University of Kentucky, Kentucky Clinic, K454, Lexington, KY 40536-0284. E-mail: brink2@email.uky.edu

Abstract

Background The health benefits of breast milk for infants are well documented, but breastfeeding is avoided by many women because of concerns about a negative effect upon breast appearance. However, there is very little objective data to either support or refute this view.

Objective The purpose of this study is to identify risk factors for the development of breast ptosis after pregnancy and to determine whether breastfeeding has an adverse effect on breast shape.

Methods Charts were reviewed of all patients seeking consultation for aesthetic breast surgery between 1998 and 2006. History of pregnancies, breastfeeding, and weight gain were obtained via telephone interview. Degree of breast ptosis was determined from preoperative photos. Nulliparous women were excluded. Logistic regression analysis was performed to identify independent predictors of postpregnancy breast ptosis.

Results Ninety-three patients met the study criteria. Fifty-four patients (58%) reported a history of breastfeeding. The mean age at surgery in the breastfeeding group was 41 years, compared to 37 years in the nonbreastfeeding group. An adverse change in breast shape following pregnancy was described by 51 respondents (55%). Greater age, higher body mass index, greater number of pregnancies, larger prepregnancy bra size, and smoking were identified as significant independent risk factors for postpregnancy breast ptosis (P < .05). Breastfeeding was not found to be an independent risk factor for ptosis.

Conclusions The risk of breast ptosis increases with each pregnancy, but breastfeeding does not seem to worsen these effects. Expectant mothers should be reassured that breastfeeding does not appear to have an adverse effect upon breast appearance.

What are the Risks Associated with Formula Feeding?
A Re-Analysis and Review

1. Melinda E. McNiel MPH,
2. Miriam H. Labbok MD, MPH, FACPM,
3. Sheryl W. Abrahams MPH

Article first published online: 24 FEB 2010

DOI: 10.1111/j.1523-536X.2009.00378.x

© 2010, Copyright the Authors. Journal compilation © 2010, Wiley Periodicals, Inc.

Issue

How to Cite

McNiel, M. E., Labbok, M. H. and Abrahams, S. W. (2010), What are the Risks Associated with Formula Feeding? A Re-Analysis and Review. Birth, 37: 50–58. doi: 10.1111/j.1523-536X.2009.00378.x

Author Information

1.      Melinda E. McNiel is an MD candidate at the University of North Carolina School of Medicine, Charlotte; Miriam H. Labbok is Professor and Director and Sheryl W. Abrahams is Research and Development Consultant at the Carolina Breastfeeding Institute, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA.

*Correspondence: Address correspondence to Melinda E. McNiel, MPH, MD candidate, The University of North Carolina School of Medicine, 2632-A Park Road, Charlotte, NC 28209, USA.

Publication History

1. Issue published online: 24 FEB 2010
2. Article first published online: 24 FEB 2010
3. Accepted August 1, 2009

1. Top of page
2. Abstract
3. Methods
4. Results
5. Discussion
6. Conclusions
7. References

Abstract:  Background: Most infant feeding studies present infant formula use as “standard” practice, supporting perceptions of formula feeding as normative and hindering translation of current research into counseling messages supportive of exclusive breastfeeding. To promote optimal counseling, and to challenge researchers to use exclusive breastfeeding as the standard, we have reviewed the scientific literature on exclusive breastfeeding and converted reported odds ratios to allow discussion of the “risks” of any formula use.

Methods: Studies indexed in PubMed that investigated the association between exclusive breastfeeding and otitis media, asthma, types 1 and 2 diabetes, atopic dermatitis, and infant hospitalization secondary to lower respiratory tract diseases were reviewed. Findings were reconstructed with exclusive breastfeeding as the standard, and levels of significance calculated.

Results: When exclusive breastfeeding is set as the normative standard, the re-calculated odds ratios communicate the risks of any formula use. For example, any formula use in the first  6 months is significantly associated with increased incidence of otitis media (OR: 1.78, 95% CI: 1.19, 2.70 and OR: 4.55, 95% CI: 1.64, 12.50 in the available studies; pooled OR for any formula in the first 3 mo: 2.00, 95% CI: 1.40, 2.78). Only shorter durations of exclusive breastfeeding are available to use as standards for calculating the effect of “any formula use” for type 1 diabetes, asthma, atopic dermatitis, and hospitalization secondary to lower respiratory tract infections.

Conclusions: Exclusive breastfeeding is an optimal practice, compared with which other infant feeding practices carry risks. Further studies on the influence of presenting exclusive breastfeeding as the standard in research studies and counseling messages are recommended. (BIRTH 37:1 March 2010)

Exclusive breastfeeding is the recommended source of nutrition for the first 6 months of an infant’s life and should be regarded as such in analytical approaches used in the study of infant feeding (1,2). Yet, despite the strength of the data and the recommendations supporting exclusive breastfeeding for infants 0 to 6 months old (1,2), analytical approaches to the study of infant feeding rarely set exclusive breastfeeding as the norm with which any other feeding approach should be compared.

In most studies on infant feeding, findings are presented in a manner that states the benefits of breastfeeding, thereby confirming formula use as the standard for comparison. In fact, a recent review determined that the titles of many studies are misleading and imply that breastfeeding is associated with increased risk of illness (3). This analytical construction of formula use as the norm and breastfeeding as the deviant, or experimental, behavior is consistent with current social conceptions of infant feeding in developed nations, but inconsistent with the accepted use of the proved optimal treatment approach as the standard, or control, group in research design.

Few women and health care providers in the United States have grown up exposed to the sights and sounds of breastfeeding as “normal” (4–7). Formative research conducted for the U.S. Department of Health and Human Services National Breastfeeding Awareness Campaign confirmed that breastfeeding was seen as the “ideal” and formula use as the “standard,” rather than inferior, behavior among focus group participants (6). In a national survey of infant feeding practices, fewer than 60 percent of respondents believed that “women should have the right to breastfeed in public,” and less than 40 percent agreed that “it is appropriate to show a woman breastfeeding her baby on TV programs” (7). Perceptions of formula feeding as the standard practice have obscured its health risks—fewer than one-half of survey respondents agreed that “feeding a baby formula instead of breast milk increases the chance that the baby will get sick” (7).

Clearly, it is important to explore how prevailing norms can be readjusted to improve suboptimal breastfeeding rates in the developed world. Research on the development of social norms suggests that, “new norms are thought to emerge when costs of compliance with existing norms become too high relative to the rewards” (8). A negative, or disincentive, value from feedback or other sources of information can also influence the construction of behavioral norms by emphasizing the dangers of not practicing a particular behavior (9,10). Studies specific to infant feeding behaviors have shown that breastfeeding intentions and behavior can be predicted and understood through constructs of the Theory of Reasoned Action, the Transtheoretical Model, and the Integrated Change Model. Elements of each of these models emphasize that the likelihood of formula feeding would decrease as its perceived risk-to-benefit ratio increases (11–14). Therefore, to encourage exclusive breastfeeding and its social acceptance, it may be reasonable to underscore the present risks (disincentives) of the alternative, that is, formula feeding, in a manner whereby the health costs of formula use are appropriately perceived as high.

This paper seeks to re-position breastfeeding as a natural, normative behavior in the minds of women’s and children’s health care providers by reconfiguring the reported statistics to reflect the risks of formula use rather than the “benefits of breastfeeding.” Specifically, we present odds and risks ratios calculated to reflect the increase in risks of adverse outcomes as a result of formula use. In doing so, we provide health professionals with the quantitative and qualitative information needed to counsel patients in a manner consistent with United States and international recommendations for exclusive breastfeeding.

1. Top of page
2. Abstract
3. Methods
4. Results
5. Discussion
6. Conclusions
7. References

This secondary analysis focused on studies included in the U.S. Agency for Healthcare Research and Quality (AHRQ)-sponsored review of breastfeeding and maternal and infant health outcomes in the developed world (15). The studies addressed eight childhood conditions, including: acute otitis media, atopic dermatitis, lower respiratory tract infections, asthma, type 1 diabetes, and type 2 diabetes. The complete original publications were obtained, and the study design, population size, and definition of breastfeeding were recorded, verified, or both. In addition, a PubMed search was conducted by entering the outcome variables listed before and exclusive breastfeeding and odds ratio. Other terms used were: exclusive breastfeeding, exclusive breast-feeding, exclusive breast feeding, and exclusive lactation.

We evaluated only studies that reported “exclusively breastfed,”“fully breastfed,” or “totally breastfed” as a comparison group. Lack of exclusive breastfeeding in developed countries is an appropriate proxy indicator of formula feeding. Data based on mixed formula and breastfeeding (“partial,”“ever,”“predominately,” or “mixed”) or on an indeterminate minimal duration of exclusive breastfeeding were excluded. Based on the definitions provided, we assumed that “exclusive,”“fully,” and “totally” breastfed infants received no formula within the given time period unless the study mentioned otherwise. Bottle-feeding with expressed human milk was considered the same as breastfeeding for this study. By selecting studies in which the researchers’ definition of “exclusive” or “fully breastfed” excluded any formula use, we ensured that the inverse odds ratios or risk ratios served as true proxies for any formula use during the specified time period.

Odds and risk ratios were taken directly from the original studies or from the AHRQ-sponsored review. Odds and risk ratios, with their corresponding confidence intervals, were calculated by creating the inverse value. p values were constructed for the odds and risk ratios listed in the meta-analysis and original studies using Microsoft Excel.

Otitis Media

Otitis media is a common childhood illness that currently affects most children by the time they are  6 years old (15,16). Table 1 presents the articles reviewed and the association between formula feeding and otitis media. Each of the studies identified achieves statistical significance in the association between formula use and increased occurrence of otitis media. The pooled odds ratio for otitis media if any formula is introduced in the first 3 to 6 months is 2.00 (95% CI: 1.40, 2.78).

Asthma

Asthma (also referred to as recurrent or allergic wheezing) is a highly prevalent chronic disease that affects increasing numbers of children (15,17). One of the greatest risk factors for asthma is family history (15,18). Lack of breastfeeding has been shown to lower the risk of asthma in some studies and increase the risk in others. These contradictory results could be explained by study design differences and variable lengths of breastfeeding in addition to variations in familial history (19). Several studies have focused on maternal diet with the assumption that the composition of the mother’s milk differs between asthmatics and nonasthmatics (20). Potential confounders in studies on asthma and breastfeeding include age and socioeconomic status as well as parental smoking and family history (15).

Table 2 presents the articles reviewed and measures of the association between formula feeding and asthma. Six of the eight studies measuring asthma risk with positive family history reported that formula use is associated with increased risk of asthma, but of these six, only one achieved statistical significance: the case-controlled study (p = 0.030). Within the group of studies measuring asthma risk with a negative family history, five of the seven studies demonstrated a positive association between formula use and increased asthma, but only two of these are statistically significant, a cohort of 2,187 (p = 0.027) and one of 3,384 (p = 0.011).

Type 1 Diabetes

Type 1 diabetes mellitus is a disorder in which autoimmune beta-cell destruction leads to decreased levels of insulin. Human milk may provide protection against the onset of type 1 diabetes by conferring passive immunity through secretory immunoglobulin A antibodies and increased β-cell proliferation, and by delaying exposure to possible food antigens (15).

Table 3 presents the association between formula feeding and type 1 diabetes. In two studies on type 1 diabetes, McKinney et al found a significant association between early formula use and increased type 1 diabetes (p = 0.01). In Tenconi’s study, one of the few studies that was constructed to assess the risk of formula use (as opposed to the benefits of breastfeeding), the association did not achieve significance.

Type 2 Diabetes

Type 2 diabetes mellitus is an increasingly prevalent disorder in which the body has developed a resistance to insulin and insulin receptors, resulting in high blood sugar levels. It has been proposed that the polyunsaturated fatty acids contained in breastmilk maintain adequate numbers of insulin receptors in the brain and thereby regulate long-term glucose and insulin metabolism (21). Table 4 presents the association between formula feeding and type 2 diabetes.

Atopic Dermatitis

Atopic dermatitis is an increasingly prevalent chronic inflammatory skin disease that is considered to be a result of both genetic and environmental factors. Studies on the association of breastfeeding with atopic dermatitis have yielded mixed results, some suggesting a protective effect, others showing no significant relationship, and two showing a positive association between breastfeeding and atopic disorders (22,23). Table 5 presents the association between formula feeding and atopic dermatitis. Eight of the 13 studies of atopic dermatitis with a positive family history reported a positive association between formula use and increased dermatitis, but only two achieved significance. Four of the six studies of atopic dermatitis with a negative family history found an association between formula use and increased dermatitis but none achieved statistical significance.

Hospitalization Secondary to Lower Respiratory Tract Infections

Respiratory infection is reported to be the most common medical problem and leading cause of hospitalization among infants and children (15,24). Immunoglobulins found in human milk are believed to bolster infantile immune systems and protect against infections such as those affecting the lower respiratory tract (25). Table 6 presents the association between formula feeding and hospitalization secondary to lower respiratory tract infections. All studies found a positive association between formula use and increased hospitalization owing to lower respiratory tract infections, with two achieving statistical significance.

Overall, the results revealed that “any formula use” is associated with increased incidence of otitis media, asthma, type 1 diabetes, type 2 diabetes, atopic dermatitis, and hospitalization secondary to lower respiratory tract infections in infants in multiple studies. In many of these studies, this positive association does not achieve statistical significance; however, it is important to note that no study found a protective effect of formula use.

1. Top of page
2. Abstract
3. Methods
4. Results
5. Discussion
6. Conclusions
7. References

These secondary analyses were undertaken to allow support for healthy infant feeding behaviors by taking the available evidence and re-expressing it as risks, or health costs, of formula use. Expressed in this manner, behavioral theory would argue that the risk of formula use becomes too high relative to the “rewards,” and families would be increasingly likely to choose exclusive breastfeeding. This construct supports the feasibility of the creation of a social norm based on the perceived costs of compliance with existing formula-use norms. In this manner, the data provided should aid in clinical counseling and in health social marketing, and encourage researchers to reconsider the selection of standard and experimental groups in the study of infant feeding. In summary, expression of the “risks of formula use” rather than only the “benefits of breastfeeding” could modify general perception, inform and reform clinical counseling, and lead to normalization of optimal infant feeding, that is, exclusive breastfeeding.

One of the strengths of this analysis is that it is based on studies with exclusive breastfeeding as the reference rather than “any breastfeeding” or a continuum of breastfeeding definitions. This reconstruction allowed us both to create a more clearly defined standard for the definition of “any formula use” versus exclusive breastfeeding and to address the recommendation of optimal feeding. In addition, because the durations of exclusive breastfeeding in the studies vary from only 0 to 6 months, any formula use is then compared with a variety of durations of optimal feeding. The fact that the odds and risk ratios remain significant even with shorter durations of exclusive breastfeeding would indicate that this analysis represents a conservative picture of the potential risks of any formula use. If more studies included 6 months of exclusive breastfeeding, we would expect more findings to achieve significance. Finally, by including expressed milk in our definition of “exclusively breastfed,” we allowed for another possible underestimation of potential risks of nonoptimal feeding.

This analysis is limited primarily by the fact that very few studies have used exclusive breastfeeding for 6 months, the inverse of which is our proxy for any formula use within the first 6 months, as a comparison group. When more studies are available, it will be easier to provide this information. Another major limitation is that the definition of exclusive breastfeeding also varied across the studies in other ways. For example, some studies defined the exclusive breastfeeding groups as “not receiving any formula.” Although this definition was acceptable for our data calculations on risks of formula use, these groups might have been introducing nonformula supplements such as water to their infants, and the effect of completely exclusive breastfeeding would be further underestimated. The studies reviewed also included a wide range of study designs with varying durations of exclusive breastfeeding. Therefore these analyses are limited in that we cannot quantify the formula use but, rather, can only state the calculated risks related to “any formula use.” Furthermore, no validation method was performed on the mothers’ reporting in these studies. As with most literature reviews, our results may have been affected by publication bias and, even though much research has been conducted on breastfeeding and associated health outcomes, it is limited by the impossibility of blinded case-control design. As a result, we conclude that increased attention should be paid in future studies to definitions of breastfeeding, full description of feeding patterns, durations of exclusive breastfeeding, and use of exclusive as the standard.

The odds/risk ratio construct using exclusive breastfeeding as the norm is most appropriate given the global acceptance that exclusive breastfeeding is optimal for health, survival, and development of the young infant, and therefore should be treated as the best available standard for feeding in this age group. Now that these figures are available, we hope that future research will be conducted on how mothers and their health care providers and others respond to the new risk language and if rates of exclusive breastfeeding are influenced as a result.

Conclusions

Top of page

1. Abstract
2. Methods
3. Results
4. Discussion
5. Conclusions
6. References

The contribution of these analyses is that the presentation of the results in this manner provides the reader with data to view exclusive breastfeeding as normal and formula use as the health-risk behavior. This language should be useful for educating health care workers, patients, and the general public as to what is optimal, normal infant feeding behavior and what is, by definition, deviant or experimental. By providing the results in this manner we are emphasizing the disincentives of the risk behavior, in this case any formula use, and avoiding language that prevents exclusive breastfeeding from being perceived as the social norm. Furthermore, standards for research design demand that alternative interventions be compared with what is considered to be the current “best” approach. Therefore, it follows that breastfeeding research should construct a study design in this manner, with 6 months of exclusive breastfeeding as the standard against which any other form of feeding should be compared. We assume that when more studies portray their results in this format, we will begin to see a widespread adjustment in the language and hence the attitudes and practices related to infant feeding, favoring the healthful normative practice of exclusive breastfeeding.

References

Top of page

1. Abstract
2. Methods
3. Results
4. Discussion
5. Conclusions
6. References

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Direct Link:

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Drug and Lactation Database – Alcohol
CASRN: 64-17-5

http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~Fbz8ff:1

Drug Levels and Effects:

Summary of Use during Lactation:
The effects of maternal alcohol (ethanol) ingestion during lactation are complex and depend on the pattern of maternal drinking. Alcohol decreases milk production with 5 drinks or more decreasing milk letdown and disrupting nursing until maternal alcohol levels decrease. Beer may increase serum prolactin levels during nursing because of polysaccharides from barley and hops. Women with a family history of alcoholism have a blunted prolactin response following breast stimulation and tend to breastfeed more frequently to compensate.

Breastmilk alcohol levels closely parallel blood alcohol levels. The highest alcohol levels in milk occur 30 to 60 minutes after an alcoholic beverage, but food delays the time of peak milk alcohol levels. Nursing after 1 or 2 drinks (including beer) can decrease the infant’s milk intake by 20 to 23% and cause infant agitation and poor sleep patterns. The long-term effects of daily use of alcohol on the infant are unclear. Some evidence indicates that infant growth and motor function may be negatively affected by 1 drink or more daily, but other studies have not confirmed these findings. Heavy maternal use may cause excessive sedation, fluid retention, and hormone imbalances in breastfed infants.

Casual use of alcohol (such as 1 glass of wine or beer per day) is unlikely to cause either short- or long-term problems in the nursing infant, especially if the mother waits 2 to 2.5 hours per drink before nursing, and does not appear to affect breastfeeding duration. Daily heavy use of alcohol (more than 2 drinks daily) may affect infants negatively and appears to decrease the length of time that mothers breastfeed their infants. Nursing or pumping within 1 hour before ingesting alcohol may slightly reduce the subsequent amounts of alcohol in breastmilk.

Drug Levels:
The alcohol (absolute ethanol) content of various drinks are as follows: 12 fluid ounces of beer (4.5%) = 12.6 g; 4 fluid ounces of table wine (12%) = 11.2 g; 1 fluid ounce of whiskey (100 proof) = 11.7 g. Blood alcohol is often reported as a percent; a concentration of 1 g/L of alcohol is equivalent to 0.1%.

Maternal Levels. Five nursing mothers drank 0.4 grams/kg of alcohol as vodka (about 2 drinks for a 60 kg woman) over 1 minute after a standard breakfast and followed the drink with 80 mL of water. Blood and milk samples were collected over the next 3 hours. Eight additional women who were not breastfeeding followed the same protocol. Blood and milk alcohol levels had a later peak in lactating women (48 minutes) than in the lactating women (31 minutes). The bioavailability of alcohol in the lactating women was 74% of bioavailability in the nonlactating women; peak blood alcohol concentrations were numerically lower, but not statistically different from the nonlactating women. Milk alcohol levels closely paralleled blood alcohol levels with an average peak level of 0.44 g/L, falling to about 0.35 g/L at 90 minutes and about 0.09 g/L at 3 hours after the dose.[1]

Twelve women between 4 and 41 weeks postpartum drank a 0.6 grams/kg of alcohol (about 3 drinks for a 60 kg woman) as a 15% solution over 5 minutes on an empty stomach. Blood and milk samples were obtained every 30 minutes for 2 hours. Alcohol concentrations in milk closely paralleled blood concentrations with the highest concentration averaging 1.05 g/L at 1 hour after the dose. By 2 hours, the alcohol concentration in milk was 0.7 g/L. Acetaldehyde, the major metabolite of alcohol, was undetectable in milk (assay limit not stated), but was detectable in maternal blood.[2]

Eight nursing mothers with infants ranging in age from 6 weeks to 2 years 9 months rapidly drank from 0.46 to 1.5 grams/kg of alcohol after a small meal. The time of peak alcohol concentrations varied from 1 to 2.5 hours after the initial ingestion of alcohol; however, some of the women drank their alcoholic beverage over a 1 hour period. Both fore- and hindmilk levels closely paralleled blood alcohol concentrations.[3]

Twelve nursing mothers with infants 25 to 216 days of age drank 0.3 grams/kg of alcohol (about 1.5 drinks for a 60 kg woman) in orange juice over 15 minutes in the morning. Prior food intake was not controlled. Milk samples were collected over 3 hours. The average peak level of alcohol in milk was 0.32 g/L at 1 hours after the end of alcohol ingestion. Milk alcohol concentrations were 0.2 g/L at 2 hours and 0.05 g/L at 3 hours after the end of alcohol ingestion. Using the volume of milk taken by the infant at the one nearest nursing time, the authors estimated that a breastfed infant would receive between 0.5 to 3.3% of the mothers weight-adjusted dosage.[4]

Two groups of Mexican mothers were studied after receiving an average of either 0.21 or 0.4 grams/kg of alcohol as pulque after breakfast. Blood and milk samples were taken at 60, 90 and 120 minutes after pulque ingestion. They were exclusively breastfeeding their infants who were 3 to 21 months of age. Milk alcohol concentrations paralleled blood alcohol, with the highest milk levels at the first measurement at 60 minutes after ingestion. The group of mothers who consumed higher doses of alcohol eliminated it more slowly from blood and milk.[5]

A dose of 0.3 grams/kg of alcohol (about 1.5 drinks for a 60 kg woman) was administered over 15 minutes to 23 Chinese nursing mothers in a chicken-based soup following a cereal snack. Samples of blood and milk were taken during the following 135 minutes. The time of peak milk alcohol levels varied among women between 20 and 40 minutes after the dose. Milk alcohol levels were similar to blood levels, but fell slightly more slowly. At 135 minutes after soup ingestion, the average breastmilk alcohol concentration was 9.05 mg/dL. The authors estimated that milk alcohol levels returned to 0 at about 175 minutes after ingestion.[6][7]

A study compared alcohol pharmacokinetics in 20 lactating women to that in 9 formula-feeding women and 15 nulliparous women. Women were tested twice, once fasting and once after a standard breakfast. Subjects received 0.4 grams/kg of alcohol (about 2 drinks for a 60 kg woman) in 2 doses 5 minutes apart, an hour after the meal on the fed days. Blood alcohol was estimated from breath alcohol levels over a 205 minute period. The average bioavailability of alcohol in the lactating women was 82% of bioavailability in the nonlactating women; peak blood alcohol concentrations in the lactating women were lower than in the nonlactating women, especially than the nulliparous women. Postpartum women, both lactating and nonlactating, felt sedated by the alcohol for a shorter period of time than nulliparous women.[8]

A nomogram was developed using pharmacokinetic principles to estimate the duration of alcohol in milk. The time to eliminate a standard drink of about 12 g of alcohol varied with the weight of the woman. For a 54 kg (120 lb) woman, 2.5 hours after finishing the drink is required to eliminate the alcohol from her milk. For a 68 kg (150 lb) woman 2.25 hours is required ; for an 82 kg (180 lb) woman, 2 hours is required. For each additional drink consumed, the same number of hours should pass. For example, a 150 kg woman consuming 4 drinks should wait 9 hours before resuming breastfeeding to ensure that the infant does not receive any alcohol.[9] A study of 10 women of varying weights who consumed 16 fluid ounces of table wine found general agreement between their results and this nomogram.[10]

Sixteen lactating women who were 3 to 5 months postpartum pumped milk either 1 hour before or 0.6 hours after ingesting 0.4 mg/kg of ethanol. Blood alcohol concentrations were measured several times between 0.4 and 3.4 hours after alcohol ingestion. Each woman underwent this test on 2 occasions, once fasting and once after a meal. Eating before alcohol ingestion reduced and delayed the peak blood alcohol concentrations, and reduced the total alcohol absorption and elimination rate. Pumping before alcohol ingestion caused similar effects, but of a smaller magnitude, and the two effects were additive or synergistic.[11] Milk alcohol concentrations were not measured, but likely paralleled the blood concentrations closely.

Infant Levels. Relevant published information was not found as of the revision date.

Effects in Breastfed Infants:
A nursing mother was drinking large amounts of quinine wine, wine, champagne, beer and liquors. Her infant had been gaining 30 g of weight daily until he weighed nearly 6 kg at 5 weeks of age. The infant had been restless and sleepless for several days when he suffered from violent fits and tonic-clonic seizures that required medical treatment. After he was taken off the mother’s breast and began to be nursed by a wet nurse, his weight quickly dropped by 200 g in 3 days and fell into a pattern of calm sleep.[12]

A similar case of chronic heavy alcohol use by a nursing mother resulted in pseudo-Cushing syndrome in her 4-month-old breastfed infant. The infant had a bloated appearance, excessive wight gain and diminished length for age. The mother reported drinking 50 cans of beer weekly and “generous” amounts of other alcoholic beverages to increase her milk supply. The infant’s symptoms resolved and growth pattern returned to normal after her mother stopped consuming alcohol.[13]

A series of 23 cases of severe thrombocytopenia and bleeding were reported among 21- to 60-day old breastfed infants of Chinese women in Singapore over a 5-year period. None of the infants had received prophylactic vitamin K at birth and all of their mothers had been taking alcohol tonics after each meal beginning at 7 to 10 days after delivery which was a common practice among only the Chinese in the mixed ethnic population delivering at the hospital. Most of the infants had also been receiving 5 to 15 mL daily of “gripe water” which had an alcohol content of about 5%. The authors attributed these cases to the lack of prophylactic vitamin K (which was common practice at the time) and increased clotting factor degradation caused by alcohol.[14]

A woman who drank 750 mL of port wine in 24 hours noticed that her breastfed 8-day-old had a deep unarousable sleep, snoring, pain insensitivity, inability to suck, excessive perspiration and a feeble pulse. These symptoms were attributed to the very young age of the infant and the large amount of alcohol consumed.[15]

In a series of studies, investigators measured the effect of maternal alcohol use on their breastfed infants. In one study, 12 nursing mothers with infants 25 to 216 days of age drank 0.3 grams/kg of alcohol (about 1.5 drinks for a 60 kg woman) in orange juice over 15 minutes in the morning. On a separate occasion, they drank an equal volume of orange juice.[4] In another study, 12 nursing mothers nursing infants with a median age of 150 days drank 0.3 grams/kg of alcohol as beer or the same volume of nonalcoholic beer on a separate occasion.[16] In a third study, 12 nursing mothers with infants averaging 3.1 months of age drank 0.3 grams/kg of alcohol in orange juice over 15 minutes in the morning. On a separate occasion, they drank an equal volume of orange juice In both studies, infants who drank milk that contained alcohol consumed 20 to 23% less milk during the 3- or 4-hour testing session, even though the time spent at the breast and number of sucks was unchanged. Mothers could perceive no difference in milk production or nursing behavior in their infants. Infants sucked more vigorously on a bottle containing their mothers’ milk spiked with alcohol than on mothers’ milk alone.[17] In a study in which infants were weighed by the mothers before and after each feeding for the next 16 hours (20 hours total), infants increased the number of nursings during the period of 8 to 12 hours after the alcohol intake such that the total amount of milk consumed during the 20-hour period did not differ between the alcohol and non-alcohol days.[18]

In studies that measured infant sleep, infants slept more frequently for shorter periods of time during the 3.5 to 4 hours after alcohol intake, whether it was after mothers drank 0.3 grams/kg of alcohol before breastfeeding or infants were given their mothers’ milk spiked with an amount of alcohol (32 mg/100 mL) equivalent to that at 1 hour after maternal ingestion of 0.3 grams/kg of alcohol.[4][19][20] After ingesting the alcohol-containing milk after maternal consumption of 0.3 grams/kg of alcohol, 14 infants from 4 to 11 weeks of age infants were observed for 1 hour after milk ingestion. Their behavioral state changed more frequently, they slept less, cried more and startled more than after consuming milk without alcohol. Mother-infant interactions were more conflictive after alcohol intake which may partially explain increased infant arousal after maternal and infant alcohol ingestion.[21] A study that monitored the infants during the 24-hour period after maternal alcohol ingestion revealed that the infants compensated by spending more time in active (rapid eye movement) sleep from 3.5 hours to 24 hours with no further alcohol intake.[20]

Long-term effects of alcohol ingestion during breastfeeding were studied in 2 separate populations by one group of investigators. In the first study, alcohol intake of more than 1 drink daily during nursing produced a measurable decrease in motor function development, but not mental development at 1 year of age.[22] A later follow-up study found no decrements in performance of 18-month-old infants who were breastfed by mothers who consumed alcohol.[23]

Studies have examined the effects of ingestion of pulque, an alcohol-containing drink made from agave cactus, in rural Mexican women. Most of the women had ingested pulque daily during pregnancy and lactation. One study found no effects on weight or length growth velocity among the 32 infants at 3 and 6 months of age whose mothers ingested an average of about 30 g of alcohol daily compared to the infants of 62 infants who did not drink pulque.[24] Another study compared the growth of 40 infants whose mothers ingested pulque during lactation and 18 whose mothers did not. Mothers who consumed pulque ingested an average of 16.3 g daily. The infants whose mothers ingested pulque regularly had poorer growth between 1 and 57 months and smaller size at 57 months.[25]

A retrospective study of 222 inner city women reported only as an abstract found that 1-year-old breastfed infants scored higher on language skills and motor development and had fewer hearing problems than nonbreastfed infants. Alcohol use by the mothers did not decrease the beneficial effects of breastfeeding.[26]

Possible Effects on Lactation:
Studies in mothers who were 2 to 8 days postpartum found that acute doses of alcohol infused intravenously reduced the oxytocin-mediated milk ejection reflex following infant sucking. The effect could be overridden by administration of exogenous oxytocin, indicating that alcohol inhibits oxytocin release, not its effect on the breast.[27] Alcohol doses of 0.5 to 0.99 grams/kg reduced oxytocin response to infants sucking by 18%; doses of 1 to 1.49 grams/kg reduced the response by 62%; and doses from 1.5 to 1.99 grams/kg reduced the response by 80%. Alcohol also increased the time for letdown to occur after nipple stimulation, from 29 seconds to 64 seconds with doses of 1 to 1.49 grams/kg and from 38 seconds to 331 seconds with doses of 1.5 to 1.99 grams/kg.[28] Other investigators found that drinking 100 mL of whiskey containing a total of 50 mL of absolute alcohol (about 4 drinks in a 60 kg woman) abolished the rise in serum oxytocin in response to breast stimulation with a breast pump in 16 nonpregnant, nonlactating women. Pretreatment with naloxone blunted alcohol‘s inhibitory effect on oxytocin release.[29]

Acute alcohol ingestion can either increase, decrease or have no effect on serum prolactin in nonpregnant, nonlactating women.[30][31][32]

Drinking 100 mL of whiskey containing a total of 50 mL of absolute alcohol lessened the increase in serum prolactin in response to breast stimulation with a breast pump in 11 nonpregnant, nonlactating women. Serum prolactin rose by 71% over baseline 20 minutes after stimulation without alcohol and only by 25% after alcohol consumption. Pretreatment with naloxone blunted alcohol‘s inhibitory effect, with the combination resulting in a 46% rise in serum prolactin over baseline.[33] It is not clear how these finding apply to lactating women.

A study on 30 lactating women who were 2 to 4 months postpartum found that the normal rise in serum prolactin was enhanced when alcohol in a dose of 0.4 g/kg was taken 35 minutes before breast stimulation with a breast pump. In subjects with a first-degree relative who was alcoholic, the increase in serum prolactin was less than in other subjects, both with and without prior alcohol consumption.[34]

Nursing mothers who ingested a 0.3 grams/kg dose of alcohol produced an average of 9.3% less milk 2 hours after the alcohol intake using a breast pump than they did when a nonalcoholic beverage was taken. The caloric content and composition of milk were not different during the two test periods.[35]

A 1-year long survey of 587 new mothers in Australia found that women who drank more than 2 standard drinks (10 grams or 12.5 mL of absolute alcohol) daily were twice a s likely to discontinue breastfeeding by 6 months postpartum.[36]

Beer specifically has a reputation for increasing milk supply. A small crossover study found that ingestion of 1 liter of beer containing 6% alcohol by 11 nonpregnant, nonlactating women increased serum prolactin by nearly 2.5-fold 30 minutes after ingestion, but sparkling water with an equivalent amount of alcohol did not.[37] In another study, 7 nonpregnant, nonlactating women were give 800 mL of beer. Six drank beer containing 4.5% alcohol and 1 woman drank nonalcoholic beer. Their average peak serum prolactin increased to 2.4 times the baseline value between 60 and 105 minutes after ingestion. The one woman who drank nonalcoholic beer had an equivalent prolactin response. Pretreatment with naloxone had no effect on the prolactin response.[38] Studies in animals indicate that a polysaccharide found in barley and malt is apparently responsible for the increase in prolactin after beer ingestion.[39][40]

The interaction between alcohol ingestion and breast pumping was investigated in a double-blind crossover study of 13 lactating women who were exclusively nursing 2- to 5-month-old infants. Compared to placebo, ingestion of 0.4 mg/kg of alcohol increased serum prolactin during the ascending phase of blood alcohol concentrations. Pumping milk from the breasts during the ascending phase of blood alcohol enhanced the prolactin response, but pumping during the descending phase of blood alcohol blunted the prolactin increase. Milk production was lower after alcohol ingestion, but unrelated to serum prolactin or alcohol blood concentrations.[41]

Twenty-three Taiwanese nursing mothers received a chicken-based soup following a cereal snack twice during the first 15 days postpartum. On one occasion the soup contained a dose of 0.3 grams/kg of alcohol (about 1.5 drinks for a 60 kg woman) and on the other occasion the soup was alcohol free. The time for the first drops of milk to be ejected was longer (2.9 vs 4.4 seconds) after the alcohol-containing soup than with the nonalcoholic soup. In addition, the triacylglycerol (14.8 vs 12.3 mg/dL) and lactate (0.8 vs 0.6 mg/dL) content of breastmilk were greater at 135 minutes after ingesting the alcohol-containing soup than the nonalcoholic soup.[7]

A study compared the prolactin response of 7 non-alcohol-dependent women with a family history of alcoholism to 21 women with no family history of alcoholism. Participants were given a dose of 0.4 g/kg of alcohol or placebo in a crossover fashion on 2 days. A breast pump was used to collect breastmilk beginning 35 minutes after ingesting the test solution. Blood samples were collected for prolactin before and at various times after beverage consumption. The women with a family history of alcoholism had reduced serum prolactin responses to breast stimulation whether or not they had consumed alcohol. They tended to nurse their infants more frequently than the other mothers, apparently as a method of compensation.[42]

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28. Coiro V, Alboni A, Gramellini D et al. Inhibition by ethanol on the oxytocin response to breast stimulation in normal women and the role of endogenous opioids. Acta Endocrinol (Copenh). 1992;126:213-6. PMID: 1574949
29. Lex BW, Ellingboe JE, Teoh SK et al. Prolactin and cortisol levels following acute alcohol challenges in women with and without a family history of alcoholism. Alcohol. 1991;8:383-7. PMID: 1797033
30. Sarkola T, Makisalo H, Fukunaga T, Eriksson CJ. Acute effect of alcohol on estradiol, estrone, progesterone, prolactin, cortisol, and luteinizing hormone in premenopausal women. Alcohol Clin Exp Res. 1999;23:976-82. PMID: 10397281
31. Soyka M, Gorig E, Naber D. Serum prolactin increase induced by ethanol–a dose-dependent effect not related to stress. Psychoneuroendocrinology. 1991;16:441-6. PMID: 1805295
32. Volpi R, Chiodera P, Gramellini D et al. Endogenous opioid mediation of the inhibitory effect of ethanol on the prolactin response to breast stimulation in normal women. Life Sci. 1994;54:739-44. PMID: 8107524
33. Mennella JA, Pepino MY. Blunted prolactin responses in lactating women with a family history of alcoholism. Alcohol Clin Exp Res. 2008;32 (Suppl. 1):31A. Abstract 082.
34. Mennella JA. Short-term effects of maternal alcohol consumption on lactational performance. Alcohol Clin Exp Res. 1998;22:1389-92. PMID: 9802517
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Substance Identification:

Substance Name: Alcohol

CAS Registry Number: 64-17-5

Drug Class:
Central Nervous System Depressants

Administrative Information:

LactMed Record Number:
584

Last Revision Date:
20100709

Disclaimer: Information presented in this database is not meant as a substitute for professional judgment. You should consult your healthcare provider for breastfeeding advice related to your particular situation. The U.S. government does not warrant or assume any liability or responsibility for the accuracy or completeness of the information on this Site.

Thomas W. Hale, R.Ph. Ph.D., member of the LLLI Health Advisory Council, Medications and Mothers’ Milk (12th ed.):

Significant amounts of alcohol are secreted into breastmilk although it is not considered harmful to the infant if the amount and duration are limited. The absolute amount of alcohol transferred into milk is generally low. Beer, but not ethanol, has been reported in a number of studies to stimulate prolactin levels and breastmilk production (1, 2, 3). Thus it is presumed that the polysaccharide from barley may be the prolactin-stimulating component of beer (4). Non-alcoholic beer is equally effective.

In a study of twelve breastfeeding mothers who ingested 0.3 g/kg of ethanol in orange juice (equivalent to 1 can of beer for the average-sized woman), the mean maximum concentration of ethanol in milk was 320 mg/L (5). This report suggests a 23% reduction (156 to 120 mL) in breastmilk production following ingestion of beer and an increase in milk odor as a function of ethanol content.

Excess levels may lead to drowsiness, deep sleep, weakness, and decreased linear growth in the infant. Maternal blood alcohol levels must attain 300 mg/dl before significant side effects are reported in the infant. Reduction of letdown is apparently dose-dependent and requires alcohol consumption of 1.5 to 1.9 gm/kg body weight (6). Other studies have suggested psychomotor delay in infants of moderate drinkers (2+ drinks daily). Avoid breastfeeding during and for 2 – 3 hours after drinking alcohol.

In an interesting study of the effect of alcohol on milk ingestion by infants, the rate of milk consumption by infants during the 4 hours immediately after exposure to alcohol (0.3 g/kg) in 12 mothers was significantly less (7). Compensatory increases in intake were then observed during the 8 – 16 hours after exposure when mothers refrained from drinking.

Adult metabolism of alcohol is approximately 1 ounce in 3 hours, so mothers who ingest alcohol in moderate amounts can generally return to breastfeeding as soon as they feel neurologically normal. Chronic or heavy consumers of alcohol should not breastfeed.

References:

1. Marks V, Wright JW. Endocrinological and metabolic effects of alcohol. Proc R Soc Med 1977; 70(5):337-344.

2. De Rosa G, Corsello SM, Rufilli MP, Della CS, Pasargiklian E. Prolactin secretion after beer. Lancet 1982; 2(8252):934.

3. Carolson HE, Wasser HL, Reidelberger RD. Beer-induced prolactin secretion: a clinical and laboratory study of the role of salsolinol. J Clin Endocrinol Metab 1985; 60(4):673-677.

4. Koletzko B, Lehner F. Beer and breastfeeding. Adv Exp Med Biol 2000; 478:23-28.

5. Mennella JA, Beauchamp GK. The transfer of alcohol to human milk. Effects on flavor and the infant’s behavior. N Engl J Med 1991; 325(14):981-985.

6. Cobo E. Effect of different doses of ethanol on the milk-ejecting reflex in lactating women. Am J Obstet Gynecol 1973; 115(6):817-821.

7. Mennella JA. Regulation of milk intake after exposure to alcohol in mothers’ milk. Alcohol Clin Exp Res 2001; 25(4):590-593.