The Science of Breastfeeding

  • Posted by Dr. Jay Gordon

Breastfeeding is an incomparable emotional experience for mothers and babies. Scientific support keeps getting stronger because solid medical research articles keep affirming the overwhelming nutritional and immunological superiority of human milk for human babies

I have always enjoyed scanning medical databases for new breastfeeding articles but this collection was gathered by Ginna Wall, MN, IBCLC and Jon Ahrendsen, MD, FAAFP who have given their kind permission for its presentation here.

For a frank discussion with your dentist, skip right to the dental caries articles. Families with premies need to look hard at the RSV research and the NEC articles among others. Neonatologists need them, too.

The brain grows better with breastmilk as has been shown over and over again in research about IQ, motor development and vision.

The articles about decreased incidence of malignancy and diabetes are worth a read in their entirety when you have a chance to get to MEDLINE or Pubmed.

An episode of diarrhea was significantly less likely to last for six or more days if an infant was breastfed for three or more months.  Baker D et al.  “Inequality in infant morbidity: causes and consequences in England in the 1990s.”  J Epidemiol Community Health 1998 Jul;52(7):451-8

The risk of developing diarrhea increases as the amount of breastmilk an infant receives decreases.  When compared with exclusively breastfed infants, infants who were exclusively formula-fed had an 80% increase in their risk of developing diarrhea.  Scariati PD et al.  “A longitudinal analysis of infant morbidity and the extent of breastfeeding in the United States.”  Pediatrics 1997 Jun;99(6):E5

Necrotizing Enterocolitis
The benefits of improved health (less sepsis and necrotizing enterocolitis) associated with the feeding of fortified human milk outweighed the slower rate of growth observed in this study of 108 preterm infants.  Infants fed human milk were discharged an average of 15 days earlier than infants preterm formula.  Schanler RJ, et al.  “Feeding strategies for premature infants: beneficial outcomes of feeding fortified human milk versus preterm formula.”  Pediatrics 1999 Jun;103(6 Pt 1):1150-7

Among babies born at more than 30 weeks gestation, confirmed necrotizing enterocolitis was rare in those whose diet included breastmilk; it was 20 times more common in those fed formula only. Lucas, A., Cole, T.J., “Breast Milk and Neonatal Necrotizing Enteral Colitis”. Lancet 1990; 336:1519-23

Otitis Media And Uris (Old News And New News)

Significantly increased risk for acute otitis media as well as prolonged duration of middle ear effusion were associated with male gender, sibling history of ear infection and not being breast fed. Teele, D.W., Epidemiology of Otitis Media During the First Seven Years of Life in Greater Boston: A prospective, Cohort Study”. J of INFEC DIS.1989.

In infants who were breast fed until at least 12 months of age, the percentage of any otitis media was 19% lower, and of prolonged episodes (> 10 days) was 80% lower than formula-fed infants.  The mean duration of episodes of otitis media was longer in formula-fed than breastfed infants (8.8 vs 5.9 days, respectively).  Dewey KG et al.  “Differences in morbidity between breast-fed and formula-fed infants.”  J Pediatr 1995 May;126(5 Pt 1):696-702

The risk of developing an ear infection increases as the amount of breastmilk an infant receives decreases.  When compared with exclusively breastfed infants, infants who were exclusively formula-fed had a 70% increase in their risk of developing an ear infection.  Scariati PD et al.  “A longitudinal analysis of infant morbidity and the extent of breastfeeding in the United States.”  Pediatrics 1997 Jun;99(6):E5

Infants who were not being breast fed were 17 times more likely than those being breast fed exclusively to be admitted to hospital for pneumonia.  Cesar JA et al.  “Impact of breast feeding on admission for pneumonia during postneonatal period in Brazil: nested case-control study.  BMJ 1999 May 15;318(7194):1316-1320

Odds of respiratory illness with maternal smoking were 7 times higher among children who were never breastfed then among those who were breastfed.  Woodward A et al.  “Acute Respiratory Illness in Adelaide Children: BreastFeeding Modifies the Effect of Passive Smoking”.  J Epidemiol Community Health 1990 Sep;44(3):224-30

Respiratory Syncytical Virus (RSV)
Breastfeeding was associated with a lower incidence of RSV infection during the first year of life. Holberg,C.J., “Risk Factors for RSV Associated Lower Respiratory Illnesses in the First Year of Life”. AM J Epidemiol 1991; 133 (135-51)

Sepsis in Preterm Infants
The incidence of any infection and sepsis/meningitis are significantly reduced in human milk-fed VLBW infants compared with exclusively formula-fed VLBW infants.  Hylander MA et al.  “Human milk feedings and infection among very low birth weight infants.”  Pediatrics 1998 Sep;102(3):E38

Urinary Tract Infections (UTI)
Breastfed infants have a relative risk of developing a UTI of 0.38 compared to formula-fed infants.  Pisacane A et al.  “Breast-feeding and urinary tract infection.”  J Pediatr 1992 Jan;120(1):87-9

Cryptorchidism (Undescended Testicle)
This case-controlled study showed a significant association of cryptorchidism and lack of breastfeeding. Mori, M. “Maternal and other factors of cryptorchidism: a case-control study in Japan” Kurume Med J, 1992:39:53-60

Gastroesophageal Reflex
Breastfed neonates demonstrate gastroesophageal reflux episodes of significantly shorter duration than formula fed neonates
. Heacock, H.J., “Influence of Breast vs. Formula Milk in Physiologic Gastroesophageal Reflux in Health Newborn Infants”. J. Pediatr Gastroenterol Nutr, 1992 January; 14(1): 41-6

Inguinal Hernia
Human milk contains gonadotropin releasing hormone, which may affect the maturation of neonatal testicular function.  This case-control study showed breastfed infants had a significant dose response reduction in inguinal hernia.  Pisacane, A. “Breast-feeding and inguinal hernia” Journal of Pediatrics 1995:Vol 127, No. 1, pp 109-111

Juvenile Rheumatoid Arthritis (JRA)
Children who have had JRA, especially pauciarticular JRA, are less likely to have been breastfed than controls
, suggesting that breast feeding may have a protective effect on the development of JRA.  Lower odds ratio were noted for increased durations of breast feeding.  Mason T et al.  “Breast feeding and the development of juvenile rheumatoid arthritis.”  J Rheumatol 1995 Jun;22(6):1166-70

Autoimmune Thyroid Disease
Feeding practices in infancy may affect the development of various autoimmune diseases later in life.
Thyroid alterations are among the most frequently encountered autoimmune conditions in children.  A detailed history of feeding practices was obtained in 59 children with autoimmune thyroid disease, their 76 healthy siblings, and 54 healthy nonrelated control children.  The frequency of feedings with soy-based milk formulas in early life was significantly higher in children with autoimmune thyroid disease (prevalence 31%) as compared with their siblings (prevalence 12%), and healthy nonrelated control children (prevalence 13%).  Fort P, et al.  Breast and soy-formula feedings in early infancy and the prevalence of autoimmune thyroid disease in children.  J Am Coll Nutr. 1990 Apr;9(2):164-7.

Pyloric Stenosis
Infants with pyloric stenosis were less likely to have been breastfed
during the first week of life.  Pisacane A, et al.  Breast feeding and hypertrophic pyloric stenosis: population based case-control study.  BMJ. 1996 Mar 23;312(7033):745-6.

Children who had ever been breast fed had a lower incidence of wheeze
than those who had not (59% and 74% respectively). The effect persisted to age 7 years in the non-atopics only, the risk of wheeze being halved in the breast fed children.  Burr ML, et al.  “Infant feeding, wheezing, and allergy: a prospective study.”  Arch Dis Child 1993 Jun;68(6):724-8

Allergies in general
2187 children
were followed to age 6 years to study the association between duration of exclusive breast feeding and asthma or atopy.  After adjustment for confounders, the introduction of milk other than breastmilk before 4 months of age was a significant risk factor for all asthma and atopy related outcomes in children aged 6 years.  A significant reduction in the risk of childhood asthma at age 6 years occurs if exclusive breast feeding is continued for at least the 4 months after birth.
Oddy WH et al.  “Association between breast feeding and asthma in 6 year old children: findings of a prospective birth cohort study.”  BMJ 1999 Sep 25;319(7213):815-9

A birth cohort was followed-up to age 4 years.  By age 4 years, 27% of the children had symptoms of allergic disease.  Family history of atopy was the single most important risk factor for atopy in children.  Sibling atopy was a stronger predictor of clinical disease than maternal or paternal atopy.  Formula-feeding before 3 months of age predisposed to asthma at age 4 years (OR: 1.8). Tariq SM, et al.  The prevalence of and risk factors for atopy in early childhood: a whole population birth cohort study.  J Allergy Clin Immunol. 1998 May;101(5):587-93.

Eczema was less common and milder in babies who were breast fed (22%) and whose mothers were on a restricted diet (48%). In infants fed casein hydrolysate, soymilk or cows milk, 21%, 63%, and 70% respectively, developed atopic eczema.  Chandra R.K., “Influence of Maternal Diet During Lactation and the Use of Formula Feed and Development of Atopic Eczema in the High Risk Infants”. Br Med J. 1989

Cognitive Development
Increasing duration of breastfeeding was associated with consistent and statistically significant increases in 1) intelligence quotient assessed at ages 8 and 9 years; 2) reading comprehension, mathematical ability, and scholastic ability assessed during the period from 10 to 13 years; 3) teacher ratings of reading and mathematics assessed at 8 and 12 years; and 4) higher levels of attainment in school leaving examinations.  Breastfeeding is associated with small but detectable increases in child cognitive ability and educational achievement. These effects are 1) pervasive, being reflected in a range of measures including standardized tests, teacher ratings, and academic outcomes in high school; and 2) relatively long-lived, extending throughout childhood into young adulthood. .  Horwood LJ, Fergusson DM.  “Breastfeeding and later cognitive and academic outcomes.”  Pediatrics 1998 Jan;101(1):E9

A review of 20 published studies on the effects of breastfeeding on infant IQ found that breastfed babies’ IQs may be 3 to 5 points higher than those of formula-fed babies.  The longer a baby is breast-fed, the greater the benefits to his or her IQ. These benefits were seen from age 6 months through 15 years.  Anderson JW et al.  American Journal of Clinical Nutrition, Oct 1999, 70.

Children who had consumed mother’s milk by tube in early weeks of life had a significantly higher IQ at 7.5 to 8 years, than those who received no maternal milk, even after adjustment for differences between groups and mothers’ educational and social class.  Lucas, A., “Breast Milk and Subsequent Intelligence Quotient in Children Born Preterm”. Lancet 1992;339:261-62

School-age phenylketonuric children who had, as infants, been breastfed 20-40 days prior to dietary intervention
scored significantly better (IQ advantage of 14.0 points, p = 0.01) than children who had been formula fed.  A 12.9 point advantage persisted also after adjusting for social and maternal education status.  Riva E et al.  “Early breastfeeding is linked to higher intelligence quotient scores in dietary treated phenylketonuric children.  Acta Paediatr 1996 Jan;85(1):56-8

In 771 low birth weight infants, babies whose mothers chose to provide breastmilk had an 8 point advantage in mean Bayley’s mental developmental index over infants of mother choosing not to do so. Morley, R., “Mothers Choice to provide Breast Milk and Developmental Outcome”. Arch Dis Child, 1988

Psychomotor and Social Development
Infants (4 to 6 months old) looked at a mobile significantly longer when tested after breastfeeding
.  This finding suggests that breastfeeding has a substantial effect on infants’ attentiveness to and interaction with their environment.  Gerrish CJ and Mennella JA.  “Short-term influence of breastfeeding on the infants’ interaction with the environment.  Dev Psychobiol 2000 Jan;36(1):40-48.

Hormones And More
Hormones, growth factors, cytokines and even whole cells are present in breastmilk and act to establish biochemical and immunological communication between mother and child.  In addition, milk nutrients such as nucleotides, glutamine and lactoferrin have been shown to influence gastrointestinal development and host defense.  Bernt KM and Walker WA.  “Human milk as a carrier of biochemical messages.”  Acta Paediatr Suppl 1999 Aug;88(430):27-41.

Erythropoietin stimulates production of red blood cells and is used in the treatment of anemia of prematurity.  Human milk contains considerable amounts of erythropoietin which resist degradation after exposure to gastric juices at physiologic pH levels. Kling PJ et al.  “Human milk as a potential enteral source of erythropoietin.”  Pediatr Res 1998 Feb;43(2):216-21

Preterm infants demonstrated a higher oxygen saturation and a higher temperature during breastfeeding than during bottle feeding, and were less likely to desaturate to <90% oxygen during breastfeeding. Blaymore Bier JA et al.  “Breastfeeding infants who were extremely low birth weight.  Pediatrics 1997 Dec;100(6):E3

In this study of 330 8-year-old children from Southern Tasmania, those who werebreastfed had higher bone mineral density at the femoral neck, lumbar spine and total body compared with those who were bottle-fed.  This association remained significant after adjustment for size, lifestyle factors and socioeconomic factors.  Breastfeeding for less than 3 months was not associated with increased bone mass at any site.  Jones G, Riley M, Dwyer T.  Breastfeeding in early life and bone mass in prepubertal children: a longitudinal study.  Osteoporos Int 2000;11(2):146-52

Breast Cancer in Adulthood
Having been breastfed as an infant has been associated with a 20-35% reduction in risk of premenopausal breast cancer in four of six studies evaluating this factor.  Potischman-N; Troisi-R.  “In-utero and early life exposures in relation to risk of breast cancer.”  Cancer-Causes-And-Control. 1999; 10 (6): 561-573

Women who were breastfed as infants, even if only for a short time, showed an approximate 25% lower risk of developing premenopausal or postmenopausal breast cancer, compared to women who were bottle-fed as an infant. Freudenheim, J. “Exposure to breastmilk in infancy and the risk of breast cancer.” Epidemiology 1994 5:324-331

Childhood Cancer
In a case-controlled study of 593 cases of cancer in Moscow children 0 to 14 years of age, the positive trend of increased risk of cancer with decreasing duration of breastfeeding was significant for all cancer combined. Smulevich VB, Solionova LG, Belyakova SV.  “Parental occupation and other factors and cancer risk in children: I. Study methodology and non-occupational factors.” Int J Cancer 1999 Dec 10;83(6):712-7.

Children who are artificially fed or breastfed for only 6 months or less, are at an increased risk of developing cancer before age 15. The risk of artificially-fed children was 1-8 times that of long-term breastfed children, and the risk for short term feeders was 1-9 times that of long term breast feeders. Davis, M.K. “Infant Feeding and Childhood Cancer.” Lancet 1988 13;2(8607):365-8.

Hodgkin’s Disease
This review of 9 published case-control studies suggests that children who are never breast-fed or are breast-fed short-term have a higher risk than those breast-fed for > 6 months of developing Hodgkin’s disease, but not non-Hodgkin’s lymphoma or acute lymphoblastic leukemia.  Davis MK.  “Review of the evidence for an association between infant feeding and childhood cancer.”  Int J Cancer Suppl 1998;11:29-33

A statistically significant protective effect against Hodgkin’s disease among children who are breastfed at least 8 months compared with children who were breastfed no more than 2 months.  Schwartzbaum, J. “An Exploratory Study of Environmental and Medical Factors Potentially Related to Childhood Cancer.” Medical & Pediatric Oncology, 1991; 19 (2):115-21.

Leukemia and Lymphoma
This case-controlled study of 117 Bedouin Arab children showed that breastfeeding for less than six months was associated with an odds ratio of 2.79 for contracting a lymphoid malignancy compared with children breastfed longer than six months.  European Journal of Cancer2001 January;37:234-238.

A total of 1744 children with acute lymphoblastic leukemia (ALL) and 1879matched control subjects, aged 1-14 years, and 456 children with acute myeloid leukemia (AML) and 539 matched control subjects, aged 1-17 years, were studied.  Ever having breast-fed was found to be associated with a 21% reduction in risk of childhood acute leukemias.  The inverse associations were stronger with longer duration of breast-feeding.  Shu XO etal, “Breast-feeding and risk of childhood acute leukemia.  J Natl Cancer Inst 1999 Oct 20;91(20):1765-72

In interviews with the mothers of 2,200 children affected by either acute lymphoblastic leukemia (ALL) or acute myeloid leukemia (AML), the infant-feeding history of each of these children was compared with that of over 2,400 healthy controls.  The investigators found that a history of breastfeeding was associated with a reduction in risk of childhood acute leukemias.  Babies who are breast-fed for as little as one month have a 20% lower risk of childhood leukemia than bottle-fed babies, and babies breast-fed for more than 6 months have an even lower risk — 30% less. Robison L et al.  Journal of the National Cancer Institute 1999;91:1765-1772.

Dental Health
In this study of 260 children ages 3-5, the authors concluded that breastfeeding for more than 40 days may act preventively and inhibit the development of nursing caries in children.  Oulis CJ et al.  “Feeding practices of Greek children with and without nursing caries.” Pediatr Dent 1999 Nov-Dec;21(7):409-16

This study estimated the prevalence of early childhood caries and related behavioral risk factors in a population of low-income, Mexican-American children in Stockton, California.  Data was collected on 220 children ages six years or less using a parent-completed questionnaire and clinical dental examinations.  Mean age at weaning from breast-or bottle-feeding and patterns of bottle use during sleep did not differ significantly between children with caries and those without. Ramos-Gomez-FJ et al.  “Assessment of early childhood caries and dietary habits in a population of migrant Hispanic children in Stockton, California.”  Journal-Of-Dentistry-For-Children 1999; 66 (6): 395-403, 366

This in-vivo and in-vitro study showed that human breastmilk is not cariogenic.  Erickson PR, Mazhari E.  “Investigation of the role of human breastmilk in caries development.”  Pediatr Dent 1999 Mar-Apr;21(2):86-90

Children who were either never breast-fed or only until 3 months exhibited a significantly higher caries prevalence than those breast-fed for a longer time.  Mattos-Graner RO et al.  “Association between caries prevalence and clinical, microbiological and dietary variables in 1.0 to 2.5-year-old Brazilian children.  Caries Res 1998;32(5):319-23

A strong association was found between exclusive bottle-feeding and anteroposterior malocclusion.  Davis DW, Bell PA.  “Infant feeding practices and occlusal outcomes: a longitudinal study.”  J Can Dent Assoc 1991 Jul;57(7):593-4

Among breastfed infants, the longer the duration of nursing the lower the incidence of malocclusion. Labbok, M.H. “Does Breast Feeding Protect against Malocclusion? An Analysis of the 1981 Child Health Supplement to the National Health Interview Survey”. American Journal of Preventive Medicine, 1987.

Diabetes is less common among breast-fed children
(6.9 and 30.1% among offspring of nondiabetic and diabetic women, respectively) than among bottle-fed children (11.9 and 43.6%, respectively).  Pettitt DJ, Knowler WC.  “Long-term effects of the intrauterine environment, birth weight, and breast-feeding in Pima Indians.”  Diabetes Care 1998 Aug;21 Suppl 2:B138-41

Children who developed IDDM in New South Wales, Australia, were compared to healthy children of the same sex and age. Those who were exclusively breastfed during their first three months of life had a 34% lower risk of developing diabetes than those who were not breastfed. Children given cow’s-milk-based formula in their first three months were 52% more likely to develop IDDM than those not given cow’s milk formula. Diabetes Care 1994;17:1381-1389, 1488-1490.

Juvenile Rheumatoid Arthritis (JRA)
Children who have had JRA, especially pauciarticular JRA, are less likely to have been breastfed than controls, suggesting that breast feeding may have a protective effect on the development of JRA.  Lower odds ratio were noted for increased durations of breast feeding.  Mason T et al.  “Breast feeding and the development of juvenile rheumatoid arthritis.”  J Rheumatol 1995 Jun;22(6):1166-70

Multiple Sclerosis
Although thought to be multifactorial in origin, and without a clearly defined etiology, lack of breastfeeding does appear to be associated with an increased incidence of multiple sclerosis. Dick, G. “The Etiology of Multiple Sclerosis.” Proc Roy Soc Med 1976;69:611-5

A German study of 9357 children aged 5-6 years of age found that infants fed only breastmilk until 3-5 months were more than a third less likely to be obese than infants fed formula from the start.  Infants breastfed exclusivelyfor 6-12 months were 43% less likely to be obese.  Breastfeeding beyond 12 months was better still, giving infants a 72% lower chance of becoming obese children.  After adjusting for potential confounding factors, breastfeeding remained a significant protective factor against the development of obesity.  von Kries, R.  “Breast feeding and obesity: cross sectional study.”  BMJ 1999; 319: 147-150.

Children who were breast fed for a longer duration were more likely, at age 15-18 years, to report higher levels of parental attachment and tended to perceive their mothers as being more caring and less overprotectivetowards them compared with bottle-fed children.  After adjustment for maternal and perinatal factors, the duration of breastfeeding remained significantly associated with adolescent perceptions of maternal care, with increasing duration of breast feeding being associated with higher levels of perceived maternal care during childhood.  Fergusson DM, Woodward LJ.  “Breast feeding and later psychosocial adjustment.”  Paediatr Perinat Epidemiol 1999 Apr;13(2):144-57

Vaccine Response
The antibody levels of immunized infants were significantly higher in the breastfed than the formula-fed group.  These findings are strong evidence that breastfeeding enhances the active humoral immune response in the first year of life.  Papst, H.F. , Spady, D.W. “Effect of Breast Feeding on Antibody Response to Conjugate Vaccine”. Lancet, 1990

The breastfed group had significantly higher antibody levels than two formula-fed groups together. Breastfed infants thus showed better serum and secretory responses to perioral and parenteral vaccines than the formula fed, whether with a conventional or low-protein content.  Van-Coric, M. “Antibody Responses to Parental & Oral Vaccines Where Impaired by Conventional and Low-Protein Formulas as Compared to Breast Feeding”. Acta Paediatr Scand 1990; 79: 1137-42

The odds ratio that a woman with osteoporosis did not breastfeed her baby was4 times higher than for a control woman.  Blaauw, R. et al. “Risk factors for development of osteoporosis in a South African population.” SAMJ 1994; 84:328-32.

Whether or not women had ever breastfed, total duration of breastfeeding and duration of breastfeeding per child were not associated with reduced bone mineral, but breastfeeding for more than 8 months was associated with greater bone mineral at some sites.  Melton L et al.  “Influence of breastfeeding and other reproductive factors on bone mass later in life.”  Osteoporos Int 1993 Mar;3(2):76-83

Mothers who breastfed exclusively or partially had significantly larger reductions in hip circumference and were less above their prepregnancy weights at 1 month postpartum than mothers who fed formula exclusively.  Kramer, F., “Breastfeeding reduces maternal lower body fat.” J Am Diet Assoc 1993;93(4):429-33

Child Abuse
Encouraging early mother-infant contact with suckling and rooming-in may provide a simple, low-cost method for reducing infant abandonment.  The mean infant abandonment rate decreased from 50.3 per 10,000 births in the first 6 years to 27.8 per 10,000 births in the next 6 years following implementation of the Baby-Friendly Hospital Initiative at a Russian hospital.  Lvoff-NM et al.  Effect of the baby-friendly initiative on infant abandonment in a Russian hospital.  Archives-Of-Pediatrics-And-Adolescent-Medicine. MAY 2000; 154(5):474-477.

A retrospective review of 800 pregnancies at one family practice revealed an association between lack of breastfeeding and physical and sexual abuse of the mother and/or her children.  This anecdotal association has not been previously reported, is worth further study using more rigorous methods.  Acheson, L., “Family Violence and Breast-feeding” Arch Fam Med July 1995; Vol 4,pp 650-652

Financial Cost to Government and Families

Food Expense
The cost to supply artificial baby milk (ABM) to one child is between $1,160 and $3,915 per year depending on the brand.  Even mothers on WIC need to buy approximately 200 cans of concentrate to feed her infant in the first year.  Breastfeeding Support Consultants, Information on Infant Feeding Costs, April 1998  (based on Illinois and North Carolina suburban supermarket prices).

Medical Expenses
In the first year of life, after adjusting for confounders, there were 2033 excess office visits, 212 excess days of hospitalization, and 609 excess prescriptions for these three illnesses per 1000 never-breastfed infants compared with 1000 infants exclusively breastfed for at least 3 months. These additional health care services cost the managed care health system between $331 and $475 per never-breastfed infant during the first year of life.  Ball TM, Wright AL.  “Health care costs of formula-feeding in the first year of life.”  Pediatrics 1999 Apr;103(4 Pt 2):870-6

Compared with formula-feeding, breast-feeding each infant enrolled in WIC saved $478 in WIC costs and Medicaid expenditures during the first 6 months of the infant’s life.  Montgomery DL, Splett PL.  “Economic benefit of breast-feeding infants enrolled in WIC.”  J Am Diet Assoc 1997 Apr;97(4):379-85

If women breast-fed each child for at least 6 months, the total projected savings over a 7.5-year period ranges from $3,442 to $6,096 per family.  This translates into an estimated yearly savings of between $459 and $808 per family.  Savings were calculated based on estimates of the resulting decrease in infant morbidity, maternal fertility, and formula purchases.  Tuttle CR, Dewey KG.  “Potential cost savings for Medi-Cal, AFDC, food stamps, and WIC programs associated with increasing breast-feeding among low-income Hmong women in California.  J Am Diet Assoc 1996 Sep;96(9):885-90