HOUSE OF REPRESENTATIVES Standing Committee on Health Aged Care and Sport : Inquiry into Allergies and Anaphylaxis submission by Maureen Minchin, Milk Matters Pty Ltd
Since 1976 I have lived and worked with allergy, published about it since 1980, and taught health professionals and others about it. I have worked with international bodies such as WHO and UNICEF on related issues, and helped develop university courses for health professionals in Australia and the UK. I am a member of both the DOHaD Society and the International Society for Research in Human Milk and Lactation.
I believe that:
- The 20th century global allergy epidemic is neither recent, nor proven most prevalent, in Australia.
- Researchers’ ignorance of the history both of allergy and infant feeding obscures clues to both causes and prevention.
- Early infant nutrition is one of the mutable keys to allergy causation, outcomes, and prevention.
- Resources need to be dedicated to understanding the impacts of early infant feeding on allergy outcomes, and devoted to helping current sufferers, as many submissions will outline, and as my books have argued since 1982.
- Equally, and even more importantly for the future health of Australia, resources need to be dedicated to making long overdue changes to professional advice and hospital practices that disrupt the highly evolved gestation-lactation continuum.
- Current allergy rates are the direct result of dismissing and ignoring parental concerns from the 1960s onwards. Allergy can arise de novo in any generation, but what Australia is facing is an epidemic of vertically communicated inflammatory diseases, allergy among them, all existing in different silos, competing for scarce funds. A narrow focus on a limited part of just one aspect of that epidemic is not all that is needed.
- Improving infant feeding practices would be fruitful across the whole inflammatory epidemic, and will more than pay for itself: the World Bank considers that “Every $1 invested is estimated to generate $35 in economic returns, making a breastfeeding strategy one of the best investments a country can make.” https://openknowledge.worldbank.org/bitstream/handle/10986/26069/ Breast_4_web.pdf
[The above is what I might have said if given 5 minutes (as requested) to address the ‘Public Hearing’ which ended 10 minutes before time.]
MAUREEN MINCHIN – MILK MATTERS – NOVEMBER 25, 2019
HOUSE OF REPRESENTATIVES ALLERGIES AND ANAPHYLAXIS INQUIRY
Outline of this submission
- Personal experience with allergy
- About truth, and understanding causes 2.1 Allergy almost non-existent three decades ago? 2.1.1 Further evidence?2.1.2 Conclusions? 2.2. Australia’s allergy rates the highest in the world? 2.2.1 Why assert that?
- How and when did population awareness increase?
- Should Australia expect ‘a tsunami of adult allergies’?
- Questions to consider 5.1 Warping normal development
- What way forward?
1. Our family’s personal experience with allergy
I have lived with allergy and its consequences since 1976, when my first child was born and sensitised to cows milk by early and unnecessary exposure to bovine formulas in hospital. Allergy has caused him multiple problems, including hospitalisations and surgery, and he has not “grown out of it”. While never challenged by an allergist to “prove” his milk allergy to their satisfaction, living provided the unexpected challenges that convinced both his respiratory physician (asthma) and his RCH gastroenterologist (ongoing gut reactions that led to and then continued after an unnecessary appendicectomy; with surgery at fifteen to deal with bowel obstruction. During this surgery he narrowly avoiding excision of damaged gut sections; the RCH surgeon gambled these might recover, but warned me that a second operation might be necessary).
Life’s inadvertent challenges included hidden milk in local previously non-allergenic bread (where a new baker “tossed in a handful of milk powder to increase protein”), drugs including a lactose-containing puffer and probiotics grown on milk, green mango juice with undeclared sweetened condensed milk, and many more such traps. From when he was four years old, it was his responsibility to interrogate mothers about the ingredients of party foods, and at some parties he could eat nothing. However tempting the food, nocturnal pain and insomnia acted as an effective deterrent to breaking his diet. So entrenched is milk in Australian diet, and so ignorant were doctors about nutrition, that in 1980 his initial diet in Ballarat Hospital after appendicectomy was prescribed as cows milk and orange juice. Repeated laparoscopies followed, as his gut spasmed and twisted, and acid stools blistered his back. Not until I substituted expressed breastmilk did he begin to heal; he came home looking like a case of kwashiorkhor, with severe protein calorie malnutrition from being in hospital!
Maternal vigilance saved him from reactions to milk in mashed potatoes when a RCH patient, allergens provided despite charts clearly labelled ‘milk-allergic’. His own vigilance ensures that he stays relatively well, although he had developed additional food allergies by the time he was diagnosed, and is sensitive to environmental chemicals as well as a variety of foods (mostly the ones I introduced at 4 months of age while he was still ‘colicky’ (read, gut-damaged), as advised by the entire medical world at the time.) Fortunately he is only sensitive, not anaphylactic, to peanuts (peanut butter in his vegies from 4 months, for extra protein); he merely develops an immediate severe frontal headache if the lid is off a jar in a large room. (The free formula I was sent home from hospital with may have been one that contained peanut oil: many formulas did in the 1970s as it was cheap, in the era before palm and coconut oil. He was fully breastfed after hospital discharge, but the formula did get used before its two year expiry date.) Having two other children, the ever- present problem was a major family stress that affected them as well.
Allergy has cost the family, like all others, vast amounts of anxiety and money and trouble over time. It has altered lives in countless ways, from sleep patterns to relationships! Our son’s problems did have one benefit: changing the family diet to exclude milk ended his father’s lifelong serious sinusitis and other health problems. We subsequently discovered from an elderly family friend that, born 1942, he had been tried on cows milk mixes after breastfeeding failed; his mother – an advantaged educated Truby King devotee – was trying goats milk mixes after “you had screamed your way through your first three months”. A third proposed repeat surgery for nasal polyps has never been needed, and the improvement in general health and mood was notable. (Serious depression frequently accompanies allergy, as a physical outcome of exposures.) So the father provided some cost savings for the taxpayer, to balance against the many public health costs from his son. Which continue. However, it is now also clear that the allergy in the previous generation makes allergy in the next more likely. Had my husband known he was cows milk allergic, and dealt with it before conception, perhaps our son’s reaction to early exposure to cows milk formulas might have been less. But that exposure would still have distorted the normal microbiome development that switches immune systems towards tolerance rather than reactivity. That fact has been known for a century, and not acted on. By contrast, my mother had been poor in 1945 and didn’t read Truby King and others who advised breastfeeding while undermining it by their ignorance of lactation physiology. She breastfed me exclusively for 9 months, as was the medical recommendation of the time, with just tastes (educational diet) before that age. For which I am extremely grateful, having had very few health problems and “a cast-iron digestion” lifelong.
In my unsolicited, ground-breaking, 1981 NHMRC submission on the subject of infant feeding and allergy, I outlined many practical changes that would have helped us, and others like us, if government had acted. That submission, and the NHMRC reply, can be read in the early editions for Food for Thought. Since the early 1980s I have been writing and teaching about infant feeding and food allergy in Australia and overseas. by the mid 1980s I had set up the first Australian course for health professionals on those subjects. I have educated literally thousands of people over time and places as varied as the US, the UK, Canada, Hong Kong, NZ, Malaysia, Europe, Vietnam… I have helped develop courses for health professionals here in Australia and the UK, including the unit on Infant Formula that is part of the UK e-Learning for Health modules overseen by the RCPCH. And I have been careful to avoid all conflict of interest by never charging parents, nor accepting industry funds. A 2016 cv (developed when nominated for the John Maddox Prize by two UK researchers previously unknown to me) is online. https://infantfeedingmatters.com/maureen- minchin/
With such a background, and despite the extraordinarily short notice from a media release 2.30pm Friday 15th for an consultation at 10am Monday 18th, I had hoped to make a brief verbal contribution to the Melbourne public consultation, simply to outline needed preventive research. I discovered speaking was strictly limited to invited participants, but unlike others, I stayed and listened to the whole day. As a result, I strongly endorse all the practical recommendations outlined by consumer advocates, and it is not my purpose in this submission to duplicate what I and they have said before this. I think that as an historian and lactation consultant involved with allergy families for over forty years I have a different but useful perspective -and corrective – to offer.
It was extremely difficult in the 1970s and 1980s to avoid allergens in poorly labelled foods and medicines, and the costs involved in management and treatment were a serious drain on our low income household. I have been pleased to see many positive changes since then. Improved food labelling and the adoption of the National Allergy Strategy have been major steps forward, even though the NAS still fails to discriminate between breastfed and formula fed infants in key areas, and seems in places to consider breastmilk/breastfeeding and infant formula interchangeable equivalents. As do most practising allergists I have come across, unless they are self-educated members of groups such as ACNEM, which take infant nutrition seriously. The persistence with which some allergists still promote 4 months as appropriate for introducing solids to breastfed children is an example of their obdurate refusal to accept the national consensus that this should happen only “when [breastfed] babies are [physiologically] ready, at around 6 months”. In the case of the formula fed, it may indeed be wiser to start at four months, on the basis that the AAP proposed in 1980, after yet another formula deficiency problem: “For breastfed infants there seems no advantage and some disadvantage to early supplements. When one uses an artificial formula, no matter how good, one must beware of possible missing ingredients. Weighing advantages and disadvantages, the Committee on Nutrition felt that 4 to 6 months of age was reasonable with present evidence.”
Science should determine guidelines for specific groups. Is this failure/refusal to offer different guidance to two very different groups of infants simple ignorance of the differences between breastmilk/breastfeeding and formula/bottlefeeding? Or is it perhaps because – like many health professionals – NAS authors are afraid of telling the truth, and possibly provoking backlash from either corporate sponsors, or from an audience of private clients whose families are likely to have been damaged by a lack of breastfeeding? Some in that demographic react with angry accusations of intent to shame and blame women, not realising that breastfeeding failure and formula use has been made inevitable by a society that normalises and supports artificial feeding.
Truth telling about infant formula is long overdue. Artificial feeding is a pandemic health risk about which parents are routinely denied accurate information on which to base important life choices, or to demand societal change to make choice implementation possible. Health regulators talk of the benefits of breastfeeding while tolerating industry marketing to suggest that it is matching breastfeeding’s effects, even adding human milk components to formula. (For example, all 200 ‘human milk oligosaccharides’ exist only in human milk. They cannot be, and are not being, added to infant formula. Genetically modified organisms are making synthetic structural analogues which are neither human nor identical. Adding just 2 synthetic analogues may be unnecessary (cf. nucleotides) or even detrimental (but will be profitable.) Allowing bovine-based additive powders to be misleadingly called “human milk fortifiers” has already caused harm to bovine-milk-allergic infants.
Accurate labelling matters greatly to food allergy sufferers, and in some cases has gone backwards. Accurate labelling of infant formula products, in this case ending false and misleading claims and inferences, would be a small and long overdue start on truth-telling that could generate pressure for societal change to protect the health of women and children, and so the whole population.
2. About truth, and understanding causes
Truth is important in history as in science. To understand the allergy epidemic in Australia, it is important to establish when it began and why, and to dispel myths spread by a variety of vested interests, some commercial and some health professional, interests increasingly co-mingled. (Conflicts of interest do not always involve obvious monetary rewards.)
I understand that the Inquiry terms of reference suggest that relieving current suffering is its primary function. Creating tax-payer funded allergy services that provide more equitable access to effective treatment – and possibly create potential “cures” – is overdue and necessary, as many submissions will attest. Only an advantaged minority can afford private practice medicine. But tests and treatments can also have unexpected adverse effects, financial and medical, if they ignore basic physiology, and if the underlying causes are not discovered and addressed thoroughly in the National Allergy Strategy.
So, to matters of truth. A Melbourne witness to this Parliamentary enquiry stated categorically that three decades ago, allergy didn’t exist in any numbers, and that now Australia is the allergy capital of the world. A catchy meme, first said some years ago, and often repeated. But is this true or false? fact or fake? science or propaganda? If untrue, surely requiring a footnote correction in Hansard, so as not to corrupt Australia’s historical record? The Committee Chair repeatedly advised, after all, that untruth in submissions amounts to lying to Parliament, and that there are penalties for making false statements, however inadvertent or unthinking.
2.1 Allergy didn’t exist in any numbers in Australia three decades ago?
Contemporary sources contradict this and prove it to be untrue.
My articles in NMAA Newsletter 1980-1981 described the huge increase of allergies noted by articulate advantaged women – and it was predominantly women – in the 1970s, who linked it to hospital practices of the time, with virtually every child given infant formula within the first hours or days after birth, and breastfeeding being sabotaged by ignorance.
Food for Thought: a Parent’s Guide to Food Intolerance (1982) contains literally pages of allergy group addresses, which increased by the 1983 edition as the book found a global audience. That book was the second version of a 1981 summary of the replies received from over 100 families in response to the articles.
Food for Thought was a multi-edition book (Allen & Unwin, OUP, Japanese editions) which described the 1970s wave of allergy then drowning parents, and which 1970’s doctors were misdiagnosing or simply denying. (That wave produced allergic children, who as parents are producing the ’tsunami’ of even more serious allergy that specialists finally noticed in the 1990s and after 2000.)
An aside for the Committee’s information: contemporary doctors explained away the 1970s infant allergy symptoms, then principally gut distress , poor sleep, and skin problems, in a number of insulting ways. Infant temperament – “you’ve just got one of those babies”. Maternal maladjustment and expectations and ineptitude – “you modern women find it hard to settle down to being a mother and the baby picks up on your stress”. Maternal age: in one group meeting we compared notes, and found that we were all either too young or too old to enjoy our babies, and so concluded the desirable age range must be before 18 or after 42… Some health professionals didn’t believe anything in milk could get past the GI tract into the baby; they knew that milk provided only passive protection, and then only if we didn’t drink, smoke, work too hard, eat the wrong foods, take medications……… Breastmilk biochemistry, the gut microbiome, programming the infant metabolome, epigenetics and vertically communicated disease, were all unknown.
2.1.1 Further evidence that infant allergy was recognised in 1970s?
The history is recounted in pages 178-199 of the 1986 and 1992 edition of Food for Thought, supplied with this submission for the Parliamentary Library. Inter alia, this includes the NHMRC 1983 statement on cows milk intolerance in infants.
In that NHMRC statement Point 4 discusses “cows milk allergy sometimes called cow’s milk protein intolerance or cows milk sensitive enteropathy,” which may cause intolerance with a wide range of symptoms having been implicated.”…from immediate to deferred and episodic. This went on to say “This disorder is considered to be common in North America where it may occur in 8 to 10% of infants. It seems to be less common in Australia with estimates of prevalence ranging from less than .05% up to 10%.” (my emphases)
Australian estimates of 10% were never popularised, simply ignored. The .05% came from a South Australian study of 500 infants in which “almost 16% of infants had symptoms which could easily be attributed to diet, but all except one have long symptom-free periods while taking cow’s milk.” (1 in 500 =.05%.) Yet being sometimes symptom-free does not preclude being allergic, as we now know.
I commented in Food for Thought that “my reading of the South Australian study was that they did indeed show that 16% of infants had symptoms which ‘could be easily attributed to diet’ and… 16% is probably about right for this generation…we can expect more to be affected in the next generation!”
And they are. Food hypersensitivity figures are far greater than the 10% figure for more narrowly defined, more readily-researched, IgE-mediated food allergy. All types of food sensitivity will involve inflammation, ie., immune activation, and all cause huge family misery. Lactation consultants understand that changing maternal diet can work to relieve breastfed babies’ symptoms (and often their mothers’) whether the sensitivity is IgE-mediated or not. In fact, it rarely matters in LC practice whether the symptoms are IgE mediated, except that this indicates a greater risk – but no certainty – of anaphylaxis.
It was clear to many 1970s families that allergy was being created in Australia by hospital practices that eliminated true exclusive breastfeeding by ensuring almost universal formula exposure, along with frequent antibiotic exposure. Both gut-altering exposures were entrenched in major maternity hospitals by the 1970s. In fact – more evidence that allergy existed – by the 1970s every Anglophone country had more than one allergy group created by concerned parents – who the above makes clear, were being patronised and dismissed. (“another muesli belt” fad).
1. Allergy in the western world was common by the 1970s.
2. Facts matter if we are to understand its causes and find its cures.
3. And grandiose statements that it didn’t exist until current researchers say it did are made only by those who do not know the history or do not listen to experienced parents and grandparents, or those working with allergic breastfeeding families. 4. There needs to be a dissenting note in Hansard.
2.2. Are Australia’s allergy rates the highest in the world?
No one knows. It may be true, of course. Quite possibly not.
Worldwide, IgE antibodies to foreign proteins in the environment are present in up to 40% -50% of the population, potentially indicating allergic sensitization. (World Health Organization. White Book on Allergy 2011-2012 Executive Summary.) On the other hand, some have doubted that IgE levels are always a negative sign of allergic sensitivity. Prof John Gerrard said that “IgE is known to play an important role in the primary immune system, at least to rival antigens. To be effective in this role IgE must be produced in the very early stages of an infection when antigenic exposure is minimal. Those who respond best to minimal low-dose stimulation can be expected to mount the most rapid and presumably effective immune response.” In other words, rapid IgE responses are possibly helpful, and he felt might even be expected in breastfed infants.
History suggests to me that the USA is likely to have the highest rates of allergy across the whole population, since fewer than one in five babies were ever breastfed by 1950, and by 1979 20% of all infant formula sold was the so-called ‘specialty’ or non-bovine formulas like Pregestimil and Nutramigen. These had been just 1% just a decade earlier. (Jelliffe and Jellife, Advances in International Maternal and Child Health, vol 1, p. 175.) The 1970s seems to have been the USA’s allergy breakout period, in children born to allergic parents themselves formula-fed in the 1940s and 1950s, and ‘colicky’ decades earlier, with early solids given.
Prominent 1970s allergists believed that “The apparent rapid increase in the development of allergic diseases in the past 30 – 40 years can, in the opinion of the author, be attributed largely to the gradual abandonment of breastfeeding when safe pasteurised milk became available about 50 years ago.” (Speer, Allergy and Immunology in Childhood. CC Thomas, 1973; p.403.)
By the 1940s to 1950s US and UK doctors were seeing many allergic patients, and describing as allergy what Australian ‘70s parents thought was allergy, using the original sense of that word (only later was the term limited to the most readily researchable form of reaction). Professor Doris Rapp’s books made it clear the problems were very common in North America – as the NHMRC noted. Advantaged parents formula fed in that period, as breastfeeding failed thanks to poor hospital practices and management advice. Many chose to formula feed, the modern un- embarrassing way that freed the mother, and which grew such very chubby babies. (The obesity and diabetes epidemics also gain momentum in this period.) I read many 1940s-1950s US and UK parenting and allergy books when writing Food for Thought.
A UK allergist asserted in 1973 that over a lifetime, around 10% of adults then manifested major allergy symptoms, and about 50%, minor ones. (Collins-Williams, Paediatric Allergy and Clinical Immunology Churchill Livingstone 1973, p.82.) Finland’s sensitisation rates reached around 50%(when Finnish breastfeeding at 6 months was just 6%) and a co-ordinated national campaign is now in place. Some Dutch studies revealed startlingly high rates – albeit in smaller cohorts where infant feeding is poorly defined, in ways which almost always favour formula feeding. (discussed in Milk Matters, pp. 106-109.)
Research reveals high and rising rates in many countries. The NHRMC almost certainly under-estimated 10-16% for early 1980s USA. Now “In the United States, approximately 30,000 cases of food anaphylaxis occur annually, 150 to 200 of which are fatal.” (DOI: https://doi.org/ 10.1097/WOX.0b013e3181898224 ) While in Australia, anaphylaxis deaths are statistically more common, but more often due to drugs and insects than to food.
Consider the medically diagnosed possible and probable asthma rate in healthy Canadian three year olds: 12%! In that CHILD cohort, modes of feeding at three months of age “are associated with asthma development. Direct breastfeeding is most protective compared with formula feeding; indirect breast milk confers intermediate protection.” In fact, formula feeding at three months resulted in three year olds with asthma at rates well above those who had been directly breastfed at three months (15% ct. 8%). As the authors concluded, “Policies that facilitate and promote direct breastfeeding could have impact on the primary prevention of asthma.” DOI:https://doi.org/10.1016/j.jpeds.2017.07.012
A 2019 review stated that “Sensitization rate to one or several allergens among school children are approaching 40 to 50% worldwide… Consistently, a recent cohort study identified 32% of children in southern Sweden suffered with at least one allergic disease and 33% of them develop multiple allergies… Front Immunol. 2019; 10: 1933. Published online 2019 Aug 23. doi: 10.3389/fimmu.2019.01933. Perhaps Sweden has the highest rates in the world? They too dropped to extremely low levels of breastfeeding before the 1970s revival. Rates improved with increased consumer education and the societal structuring that enabled women to breastfeed: paid maternity leave, etc.
Low income countries that move into now-aspirational formula feeding see inflammatory disease rates rise dramatically in the second generation. China’s allergy, diabetes, and obesity epidemics are all growing in parallel with the explosion of formula feeding: the highest rate of diabetes increase is in the under 5s. It is estimated that US$7billion is spent on marketing, many times the amount spent on product research, with the global market having expanded from US$2billion in 1980 ($500 million in the USA) to US$70billion today..
I can remember being astonished in the l960s that Americans all seemed to consult allergists- and it was unheard of among my friends (then!). Every allergy medication, in every strength and dozens of brands, can be bought freely and cheaply in every North American drugstore. (In the1980s I took advantage of that when attending ILCA Board and USAID-funded meetings. Statistics on antihistamine and steroid sales over time might shed light on relative allergy rates!)
So is Australia the country with the highest rates of allergy? Personally, I doubt it. But in the absence of any truly independent and comprehensive research, or comparable national health schemes and social equity and access to medical care, allergy rates simply can’t be compared. Don’t do the research, define allergy differently, ignore parental and healthworker experience, and you won’t have evidence of higher rates. Which governments may not want to find, since the poor might require better access to more expensive healthcare.
Does it matter that allergy researchers claim Australia is the allergy capital of the world? Yes.
Anything that misleads as to the origins of a population-wide health problem matters. Because prevention is always preferable to cure. It may not be for any who stand to gain from research into treatment and cure, but who will lose from research into prevention that involves no commercial products, no salaries for allergists and immunologists (but instead societal changes to enable better infant feeding practices and ongoing community-based support for allergic families.) Potential conflict of interest has always dogged western medicine. And it seemed to me – I may be wrong – to exist in the Melbourne hearing, as I listened to rhetorical ‘questions’ and claims putting certain things on record in Hansard.
2.2.1 Why assert that Australia has the world’s highest rates?
I suspect because it serves certain interests and what they see as the best interests of the community, and/or their businesses, to make that unproven ambit claim. Researchers, for example, need to generate funds and secure jobs from cost-cutting governments. And for that they need to generate media interest and urgency. Hyperbole is a well-worn sales tactic, as the food and drug industries know well.
Again, does this exaggeration matter? There is, after all, a sound basis for saying allergy rates are high (just not the highest in the world), and that this will cost society more if ignored. CFAR’s large community study showed 10% of year-old children had a diagnosed allergy in their narrow definition of the term. That is along the lines of what parents were saying in the 1970s, when no testing was done, and almost no baby left major hospitals without having been given at least one dose of bovine formula, supplied free by companies competing in an expanding market offering new formulations to move to after older fomulations caused problems.
By now I’d expect a reader to object: formula can’t be responsible because allergy occurs in breastfed babies. My book, Milk Matters: Infant Feeding and Immune Disorder deals with that red herring in some depth. Here I’ll simply say that breastfeeding in this generation and this country may not be as protective as it clearly was in earlier studies in many countries, including Finland. Relative risk by feeding mode has changed over time and place – but never to establish that exclusive breastfeeding is worse than infant formula, mind you! A 1930s study had found eczema was 7 times more common in formula-fed infants, and was rare in breastfed ones; 1970s and 1980s studies noted that they had never seen FPIES (food protein intolerant enterocolitis syndrome) in breastfed infants. Both eczema and FPIES now occur in breastfed infants, especially those with allergic siblings or other kin. Sometimes only the fact that formula is obviously worse keeps some mothers breastfeeding, as maternal diet restrictions are difficult, even if they quite often improve the child’s – and often the mother’s – health. Milk Matters argues that compounding intergenerational damage from parental or even grandparental formula exposure can explain this narrowing of the gap between formula and breastfeeding allergy outcomes. (Other health and lifelong developmental differences for child and mother are still highly significant, even now.)
Restoring healthy human microbiomes is likely to be a key area of both preventive and therapeutic research, and exclusive breastfeeding and improving the parental microbiomes pre- conception, and certainly prenatally, are surely part of that process. (Until recently this has not been a major interest as many allergists utilise industry’s fallible formulas. The creation in Perth of the Larsson-Rosenquist Chair in Human Lactology at the University of Western Australia offers hope that this omission will be remedied: I hope the Parliamentary Committee consulted Professor Valerie Verhasselt, or will do so, about future allergy research projects. And takes advantage of Professor Meghan Azad’s forthcoming trip to Australia in February 2020 to hear about Canada’s CHILD Study, one of the few to carefully delineate feeding practices, and so begin to uncover the significance of direct and exclusive breastfeeding.)
As Milk Matters makes clear, I think a Milk hypothesis subsumes other hypotheses. I am convinced that babies are crying in WEIRD nations because their microbiome and metabolism and gene expression have been and are being distorted by exposure to alien foods soon after birth, and by the effects of that having happened to their parents and grandparents before them. This is illustrated in a poster presented at the 2019 DOHaD World Congress (attached). The obvious conclusion I draw is the need to try reversing the key causes, which I see as the lack of breastfeeding, the misuse of infant formula, and the assumption of formulas’ total safety created by unregulated industry marketing and ignorant health professionals’ use.
3. How and when did population awareness increase?
What Australia now has, and some other countries don’t, is a middle class aware of allergies thanks to two sources:
1. Predominantly advantaged people in national networks (including ABA and childbirth education and allied health and wellness groups, unorthodox nutritionists such as Robert Buist, research-oriented doctors such as Colin Little, societies like ACNEM, the Australian College of Nutritional and Environmental Medicine) which spread via social media and education much the same information as in my books since 1982, and also later authors working with families, such as Sue Dengate, Joy Anderson, and Robyn Noble. If doctors dismissed them, parents turned to allied health professionals such as naturopaths and chiropractors willing to take time to listen and work with them. I suspect that probably nothing has done more to promote ‘alternative’ medicine than past neglect of food-related problems. This demographic of advantaged families are over-represented in most clinical trials.
2. Unregulated misleading infant formula marketing from the 1980s onward, which first promoted soy formula, then so-called ‘lactose-free” formulas, as the solution for infant gut distress, and finally the ‘comfort’/partially hydrolysed formulas formulas.
Industry marketing in the 1980s and 1990s gradually changed medical perceptions of allergy from rare to common. New products gave doctors the ability to do something simple and quick (and often useless or even harmful) about parental complaints. Uneducated professionals’ attitudes to allergy and to breastfeeding, changed in that time. It became common to suggest or prescribe formula as a solution for all unsettled, even breastfed, babies. And an allergy diagnosis was useful: assertive allergy-aware families were able to access free infant formula on prescription. (Meanwhile poor parents struggled to pay for regular formula, and their infants’ problems were seen as due to inadequate parenting.) Only over time did parents learn to regret any decision that ended breastfeeding early.
Doctors and child health nurses trusted messages from industry reps, and then from professional education sponsored by industry, that allergy exists and is common, and they should prescribe various formulas. For example, in the 1980s Mead Johnson distributed widely a leaflet saying that 13% of infants had digestive problems with regular formula. All the companies had graphic charts showing health professionals how to progress from one damaging formula to the next option; very few worked at helping mothers manage that often difficult transition, or to sustain breastfeeding. Many misleading claims about formulas were never challenged. In the UK at present the cost of these formula solutions (to be paid for by the cash-starved NHS) is driving medical resistance to an ever-increasing, social media fuelled, parental awareness that allergy iscommon. But lactation consultants report that UK allergy problems are identical to those here. Similarly, the problems resolve when LCs suggest the ideas on allergy management in print since 1982, and now updated as an e-book: Crying Babies and Food in the Early Years. https:// www.amazon.com.au/Crying-Babies-Food-early-years-ebook/dp/B01LXR34XK?
4. Should Australia expect ‘a tsunami of adult allergies’?
Yes, and Australia is already surfing massive waves badly. Especially if symptoms other then the classic few named in the accepted “allergic march” are acknowledged as allergy more broadly defined. I never could locate convincing evidence for 1980s assertions that people truly grow out of allergy – as distinct from losing certain symptoms and having some lower markers of inflammation as bodies and environments change. The working model of hospital-based immunologists was not that of intelligent families, who realise over time that while allergic symptoms can disappear, they can just as easily return, or the underlying sensitivity cause different symptoms, at times of physical or mental overload or immune challenge. I know almost no one who has “grown out of allergy”, and many who have developed different or worse symptoms over time, until they modify their allergen exposure. I also know no one with food allergies who does not also have other environmental sensitivities, and most have some respiratory issues, albeit intermittently.
Australia has developed an excellent collaboration for allergy research, CFAR, based in Murdoch Children’s Research Institute, which has done some large scale studies and come up with unsurprising forecasts that fewer children will lose symptoms because allergy does persist into adulthood, although they are hoping to find a “cure”. (Given the complexity and uniqueness of immune systems, it seems to me possible that what cures one patient may harm another. ) Unregulated experimentation with probiotics that may alter microbiomes is already being marketed everywhere in the community, and immunologists are discussing immune system modifications. Globally there are other research collaborations exploring this issue, some over a longer population lifespan or with larger cohorts. It seems likely that every profession wants to see its members knowledge utilised and the profession grow, and that every research centre wants to secure its future by profiting from their findings, or partnering with pharmaceutical firms. Academic researchers are subsidised by taxpayers, but profits from their research often go to investors, which of course adds costs to treatments, which further entrenches inequity of access.
5. Questions to consider
Is the search for commercially-viable, purchasable, cures the best use of taxpayer resources?
Might more be done to prevent future allergies?
Are both treatment and prevention strategies affordable?
If not, which most benefits the future population by promoting better community health?
I believe that this Allergy and Anaphylaxis Inquiry needs to think strategically about all options for Australia, and not be captured by existing allergy interests, or limited to practical fixes for existing victims. It needs to consider prevention by reducing damage to infants. Given the poor understanding of lactation in the general community, including among health professionals, I think it important to spell out where and how some of the harm happens.
5.1 Formula exposure has been and is warping normal immune development across whole populations: the milk hypothesis
As a result of 42 years of living with and learning about food allergy in (mostly) breastfeeding families, I believe that infant formula given neonatally has been and is damaging Australian infants. Victorian statistics state that roughly 30-70% of all Victorian newborns have had their immune development altered by exposure for foreign foods; the highest rates are in private hospitals where advantaged women learn to breastfeed.
The basis for my belief is community and personal experience, together with science and basic biology, history, common sense, and respect for the precautionary principle. Some immunologists, allergists and diabetologists fail to understand the central role of lactation in human immunity. https://infantfeedingmatters.com/intolerant-bodies-history-immune-research/
Lactation is one of the bedrocks of normal human development over millions of years. Anthropologists and evolutionary biologists agree that the large human brain dictates infant birth while organogenesis and brain development is still underway, allowing the newborn infant to further develop in the safety of the mother’s arms and the security of her milk. Lactation has evolved to present to the baby manageable trace doses of all that the mother eats and breathes, along with an immense array of bioactive factors that enable the newborn to deal appropriately with those personalised and environment-specific inputs. Over 700 species of non-pathogenic bacteria and countless other microbes are transmitted via the breast and the milk, governing the normal colonisation and development of the infant gut.
That infant gut is permeable immediately after birth to allow for the uptake of those milk bioactives, including pluripotent maternal stem cells, which transfer to virtually every organ of the baby. Such cells have been shown in animal studies to be capable of repair work, recreating an entire functioning mammary gland in an ablated area, for example. Gut bacteria will digest breastmilk and produce metabolites that influence infant development and function. The infant immune system, skewed towards reactivity as a form of protection, learns selective tolerance from breastmilk and its enormous array of living cells, hormones, enzymes, and specific anti- inflammatory factors, along with the traces of all the mother contacts or ingests or breathes.
Before lactose synthesis occurs, colostrum provides huge doses of protective proteins, and has a laxative effect that clears meconium gently as milk is produced to replace it in the gut. At the same time, the baby’s 25% excess blood volume (needed in utero) is reduced and broken down, liberating bilirubin, some of which is excreted and some recirculated through the liver. Bilirubin is a potent antioxidant provided at the time of high oxidative stress and low anti-oxidant dietary intake for the infant. Recirculation is a protective strategy, but levels that are too high for any reason can cause a degree of jaundice: readily prevented, identified, and treated. In the formula fed infant bilirubin is rapidly bound by the excess milk protein and excreted, not recirculated. This may be connected to the higher rates of chromosomal breaks and DNA damage found by cancer researchers in not- breastfed infants. (Discussed and referenced Milk Matters p. 32)
So over millions of years humans developed a unique continuum from gestation through lactation, from the womb to the world. During gestation the child is exposed via maternal blood to traces of normal maternal diet; that process continues throughout lactation. It is not surprising therefore that recent research has shown the lowest rates of peanut allergy in children whose mothers were eating peanuts during breastfeeding, and who were themselves given peanuts to eat under 12 months of age. https://www.jacionline.org/article/S0091-6749(17)31104-1/fulltext DOI: 10.1016/j.jaci.2017.06.024 The WHO advice to breastfeed exclusively until children are ready, around six months of age, and to continue breastfeeding into the second year and beyond, is being supported by this emerging research, showing that breastfeeding exclusivity, dose, and duration, together with maternal diet, all affect allergy – as well as other health – outcomes.
What happens when infant formula is introduced into that permeable newborn gut? There is very little detailed research to see what specific components and metabolites of bovine milk make their way into the child’s body, much less how they affect it. We know that some caseins are toxic to human gut cells. We know they affect brain development. And there is increasing concern about the exosomes of processed bovine milk, processed yet again in formula making.
Some things we do know. Formula’s high protein binds bilirubin and removes it from the gut. Formula puts into that gut oxidant molecules that can cause inflammation. Formula suppresses hunger and so delays the establishment of successful breastfeeding, undermining the mother’s confidence to feed her baby. Formula use testifies that health professionals think it as good as or better than mother’s own milk. Formula availability tells the mother that hospitals endorse particular brands as the best product, ensuring a 93% brand loyalty thereafter. And above all formula changes that master controller of infant development, the body microbiome. It fosters the colonisation and establishment of pathogens that produce metabolites that alter normal development, as will its quite different nutritional composition.
Does this make any biological difference to children? Are there measurable bodily tissue outcomes of artificial feeding? There certainly are. MRIs show different brain white matter growth patterns under 12 months of age, ultrasounds show different reproductive tissue growth by as early as four months postpartum, assays show different metabolites creating a different metabolism. Organ size and structure differ: for example, on average the thymus of an infant who is formula-fed is half the size of that of the breastfed infant. That thymus, until recently thought to be unimportant, is now recognised as a powerful immune organ affecting regulatory T cells. Less testicular tissue and more ovarian development at four months of age in soy fed infants may be highly significant in communities with declining sperm counts, increasing infertility, polycystic ovaries, and ovarian cancer. (Shouldn’t we find out? To my knowledge, no one has measured this in cow’s milk formula-fed babies, although the smaller amounts of oestrogen analogues in – mostly pregnant- cows’ milk are of more potent bioactivity. Hormones and enzymes are not all denatured during processing, and that milk grows a 300lb calf in 12 months.)
Mammals have evolved a complex, highly conserved survival mechanism to ensure smooth transition between the womb and world. It involves a milk that provides all the nutritional, biochemical and immunological supports an infant needs, a gut open to taking up cells, and a body needing to be everywhere colonised with harmless microbes. And into that gut, health professionals in hospitals put an alien mix of highly processed, but still bioactive, udder milk that comes in a virtual soup of synthetic and processed foodstuffs, vitamin and mineral mixes. We have known for a hundred years that affects the gut microbiome, and that will affect all development and immune function. For more information about what is affected, read Milk Matters.
Scientists are identifying causal pathways for milk’s biological effects. As BC Melnik says, “Milk is not ‘just food’ but represents a most sophisticated signalling system of mammalian evolution promoting a regulatory network for species-specific controlled m-TORC1 driven postnatal growth and metabolic programming. Milk signalling is mediated by milk-derived BCAAs, which stimulate the secretion of insulin and IGF-1. Exaggerated m-TORC-1 signalling induced by formula feeding appears to represent the underlying mechanism explaining exaggerated postnatal growth, aberrant adipogenic, hypothalamic and allergenic programming, laying the foundation for the development of the chronic diseases of civilisation, i.e., obesity, type 2 diabetes, dyslipoproteinaemia, arterial hypertension, allergic and autoimmune diseases.” Simply, as the article title says, “Milk is not just food but most likely a genetic transfection system activating mTORC1 signaling for postnatal growth.” https://nutritionj.biomedcentral.com/articles/ 10.1186/1475-2891-12-103 Milk is food, medicine, and signal.
Once changes in development and gene expression take effect, not only the index child has been changed. If male, that child will grow up to contribute half of his children’s genes, and (via sperm micro RNAs) will influence their gene expression. If a girl, that child will grow up to gestate the next generation, and there is increasing evidence that her diet, microbiome, and her metabolome affect the development of her offspring, as will her milk. As a result, a huge burden is being put on the present generation of mothers, along with stressful pressures to be an ideal weight before during and after conception and birth – which may have been made impossible by their own infant feeding!
And all that in turn will influence the next generation, and then the next. This is generalised visually in my DOHaD poster, downloadable at https://infantfeedingmatters.com/the-milk-hypothesis-illustrated/
What was crystal clear in the families that I was dealing with in the 1970s was that allergy became worse with each passing generation. To them and to me that made sense. In fact some grandparents predicted their own progression to auto-immune disease in mid-later life. So now anaphylaxis is relatively common compared to the past. Would it be, had 1980s doctors tackled causes rather than denied parental experience? How many anaphylaxis deaths might have been prevented had doctors listened in the 1970s and 1980s, and this current generation been spared early life exposure to formula and antibiotics – because hospital practices and healthworkers’ knowledge and societal structures enabling breastfeeding had all improved?
It is true that “There is conflicting evidence on the protective role of breastfeeding in relation to the development of allergic sensitisation and allergic disease. Studies vary in methodology and definition of outcomes, which lead to considerable heterogeneity. [MM: Almost none include infants exclusively breastfed from birth, e.g.] …. Existing evidence suggests that modulation of human breast milk composition has potential for preventing allergic diseases in early life.” https://www.mdpi.com/ 2072-6643/9/8/894/htm An open access article (which includes infant formula company authors) spells out more of the complexities and is a useful, if slightly dated, review (despite its serious error in citing either LEAP or EAT as indicating 3-4 months is preferable to around 6 months for the introduction of other foods to exclusively breastfed children.) https://doi.org/10.3390/nu9080894 and https://www.researchgate.net/publication/322101630_Still_LEAPing_to_wrong_conclusions? In fact, many immunologists and allergists have been very slow to recognise the central role of the breast and lactation in human immunity, as I document in an online review of an (otherwise) excellent book.. https://infantfeedingmatters.com/intolerant-bodies-history-immune-research/
6. What way forward?
Is the government simply seeking some commercially available cure that only advantaged parents can access, or the taxpayer must continue to fund in perpetuity? MCRI is looking at everything from vaccines, to using petrochemical derivatives to moisturise skin, or putting biotech solutions like probiotics in infant guts. All potential money-earners for somebody, and so costs for parents or taxpayers or both. What about the natural potential solution, to help individual mothers with their breastfeeding and their breastmilk and their diet, and bottle feeding mothers with better research and choices about formulas to avoid and to try? But of course that creates work not for medical specialists and researchers in an empire of referral and research centres, but for nutritionists and lactation consultants and child health nurses, while interested GPs would need to be recompensed for hour long consultations, not 10 minute ones. And it must mean better maternity leave and fair compensation for women doing the essential work of feeding the next generation, and an end to the increasing claims that men who have not gestated or birthed and are not breastfeeding should have as much paternity leave as women who have and are. It might even mean paying women a bonus for achieving breastfeeding goals, a strategy that in the UK has raised rates in precisely the demographic where this is needed. What is needed will be ably outlined in March 2020 by Professor Mary J Renfrew, a key figure in that UK research, speaking for the Australian Breastfeeding Association.
There are many other factors that will influence child health and development, and I discuss these in Milk Matters. But nutrition is the only postnatal factor capable of having such a powerful immediate, and intergenerational, effect. For no other factor actually creates the organs and influences their function, determines the microbiota and thus their metabolites, grows the brain and gut that will control development.
And at no other time in the child’s life is the gut evolved to be so permeable and open to that influence, taking up maternal cells that will persist in the child for many decades. (In later life when a damaged or ‘leaky’ gut allows uptake, the consequences are almost always negative. And a damaged gut is more likely if that gut never developed normally in early life, or if it acquired biofilms of pathogens that breastmilk would have displaced. Adult gut disorders are surely related.
Milk is the living tissue that programme’s child’s future development. Breastfeeding advocates don’t need to prove harm from its absence, or from the presence of ultra-processed ersatz substitutes. That can safely be assumed, given the history recounted in Milk Matters, a history derived from industry sources. The burden of proof instead lies with those who consider that interrupting complex transitions and highly evolved evolutionary safeguards is acceptable practice.
Which for me raises two questions. While deciding how to help existing allergy/anaphylaxis victims, should Australia focus on concentrating control of treatments and cures to research institutes and allergists, and not do more about postnatal nutrition? Why is there so little focus on discovering how the breastmilk of mothers differs? We have known since 1980 that an egg-allergic child responded with symptoms to his mother’s milk, but not to the milk of a donor mother eating identical amounts of egg. https:// doi.org/10.1111/j.1365-2222.1980.tb02090.x Which emphasises the point that individuals, both mothers and babies, vary.
That fact should not be used to discourage any mother from breastfeeding (though it will, given typical media reportage). Rather it is an argument for mothers getting treatment and counselling and management of their diet while breastfeeding (something not mentioned in the consultation). And it is an example of the need for far greater research here in Australia on how the breastmilk of mothers might be modified, or if not modifiable, supplemented with breastmilk from other healthy mothers, rather having infants exposed to ultra-processed formulas with high oxidant levels. Too little of all that is being researched in Australia. If CFAR hopes to become a permanent national allergy research centre, it needs to take on those non-profit concerns, and refrain from advising mothers to stop breastfeeding, as too many allergists do. (Some private Facebook pages record the consequences. (If they follow doctors’ advice to stop breastfeeding, I always advise mothers to maintain lactation by expressing milk – as in a week or two they may be dealing with more infant distress, and relactation can be difficult. Prescription of so-called hypo-allergenic formulas needs to be actively monitored and results published, not used as a way of getting mothers and babies out of doctors’ surgeries with something to try.)
I may be wrong about some details, but I am convinced that Australia will not reduce or end the anaphylaxis/allergy/inflammatory disease plague until our health systems respect the necessary continuum between womb and world, necessary for the health of both mother and child, and so our maternity hospitals and postpartum care of women and children, and societal support of mothers, is transformed.
That will not happen without a concerted strategy, and those currently involved with allergy and anaphylaxis need to be supportive of that strategy. The Royal Children’s Hospital, in which MCRI and CFAR are headquartered, and Monash Children’s Hospital both need to be a banner leaders in any such campaign. At present, I think it fair to say that these institutions are not widely recognised in the lactation community as active champions of breastfeeding.
I would be happy to discuss any aspect of the issue with all or any member of the Committee. I regret that the pressure of time does not permit me to reference this submission fully, but this Public Hearing and the resulting document were an unplanned addition to a crowded schedule. The submission can be freely circulated; I stand behind whatever I write.
I hope to see necessary edits or corrections to the Hansard record in due course.
Articles from NMAA Newsletter, August 1980 and January/February1981
Food for Thought: a parent’s guide to food intolerance various editions, 1982, 1983, 1992 (This includes early NHMRC statements and responses)
Breastfeeding Matters: what we need to know about infant feeding (1985; 1998 edition) Milk Matters: Infant Feeding and Immune Disorder (2015)
How much has milk mattered? DOHaD World Congress poster 2019 with related documents, downloadable at https://infantfeedingmatters.com/the-milk-hypothesis-illustrated/
The above materials will be posted to Canberra along with a printed copy of this submission, which I shall email directly on November 28th to meet the deadline. I hope this pdf arrives and prints out reasonably well: sometimes the translation between computer systems makes a mess of documents.
Thank you for considering the content of this document and reflecting on the issues it raised, which were raised for me by the content of the Public Hearing on Monday November 18 in Melbourne.
I should like the resources above to be housed in the Parliamentary Library once Committee members have dealt with them. If this is not possible for any reason, I will be happy to receive them by return to the address below.
Maureen Minchin PO Box 132 Newcomb Vic 3219 email@example.com http://www.infantfeedingmatters.com
Postscript. There have been minor edits to this document as I prepare to post it, but the content is not changed.