The optimal duration of exclusive breastfeeding
Since 1979, the WHO recommendation
for the duration of exclusive breastfeeding has been
'4-6 months'. In 1994 and 1996, the World Health Assembly
(WHA) and UNICEF recommended introduction of complementary
foods at the age of about six months, thus recognizing
that exclusive breastfeeding should be fostered for
about the first six months. But the WHO did not change
its previous recommendation, stating that further
evidence was needed despite the fact that the world's
experts have argued that evidence supporting the change
in the recommendation was sufficient. IBFAN has always
maintained that the delay in changing the recommendation
resulted mainly in large profits gained by infant
food manufacturers from sales of complementary foods
for two additional months of complementary feeding.
During the 53rd WHA in the year
2000, the Brazilian delegation proposed a resolution
in favour of exclusive breastfeeding for six months.
The draft resolution did not pass and the WHO Secretariat
tried to postpone any further resolution on infant
feeding to 2002. But the members of the WHO Executive
Board in January 2001 clearly stated the need for
the resolution. Therefore the Board decided to keep
the recommended duration of exclusive breastfeeding
in brackets ('4-6 months' vs 'about 6 months') until
an expert committee decided on this issue and also
decided to forward the resolution to be discussed
at the 54th WHA in May 2001.
In
March, the report issued by the Expert Committee
which was finally convened by the WHO Secretariat
put an end to the long debate by endorsing exclusive
breastfeeding for 6 months. Despite pressure from
the baby food industry and some last-minute uncertainty,
resolution WHA54.2
was eventually passed on 18
May 2001.
The resolution urges Member States
to "... support exclusive breastfeeding for six
months as a global public health recommendation taking
into account the findings of the WHO Expert Technical
Consultation on optimal duration of exclusive breastfeeding
and to provide safe and appropriate complementary
foods, with continued breastfeeding for up to two
years or beyond ....".
The Expert Committee had identified,
reviewed and evaluated more than 3,000 references.
The studies comparing exclusive or predominant breastfeeding
for about four months with the same pattern of feeding
for about six months did not show an adverse effect
of the latter on growth and major morbidity. The review,
however, could not rule out an increased risk of growth
faltering in some infants who are exclusively breastfed
for six months, particularly in populations with severe
maternal malnutrition and a high prevalence of intrauterine
growth retardation. There might also be a risk of
poorer iron status in infants exclusively breastfed
for six months in populations in which maternal iron
status and infant stores of iron are not optimal.
On the other hand, the review confirmed that exclusive
breastfeeding for six months protects against gastrointestinal
infection, even in settings where hygienically prepared
complementary foods are used, and confers an advantage
in prolonging the duration of lactational amenorrhoea
in mothers who breastfeed frequently (10-14 feeds
a day).
The recommendation to exclusively
breastfeed for six months applies to populations.
It is clear that some mothers will be unable to, or
choose not to, follow this recommendation; they should
be supported to optimize their infants’ nutrition.
Particular attention should be paid to the nutritional
status of pregnant and lactating mothers, the micronutrient
status of infants living in areas with high prevalence
of iron, zinc, and vitamin A deficiencies, the routine
care of individual infants, including assessment of
growth and of clinical signs of micronutrient deficiencies.
Refs.
WHO. Expert
consultation on the optimal duration of exclusive
breastfeeding. Conclusions and recommendations. Document
A54/INF.DOC./4, Geneva, 28-30 March 2001.
WHO. Global
strategy for infant and young child feeding. Document
A54/7, Geneva, 9 April 2001.
Key abstract
Dewey KG.
Nutrition, growth, and complementary feeding of
the breastfed infant. Pediatr Clin North Am
2001;48:87-104
The following
conclusions about infant feeding are well substantiated
by the evidence available to date, although additional
research is needed on many issues.
Breastmilk
alone can meet nutrient needs during the first 6 months,
with the possible exception of vitamin D in certain
populations, and iron in infants of relatively low
birth weight.
Complementary
foods offered before 6 months of age tend to displace
breastmilk and do not confer any growth advantage
over exclusive breastfeeding.
Breastmilk
continues to provide substantial amounts of key nutrients
well beyond the first year of life, especially protein,
fat, and most vitamins.
Breastfed
infants tend to gain less weight and usually are leaner
than are formula-fed infants in the second half of
infancy. This difference does not seem to be the result
of nutritional deficits but rather infant self-regulation
of energy intake. New growth charts based on infants
breastfed throughout the first year of life are being
developed by WHO.
The nutrients
most likely to be limiting in the diets of breastfed
infants are minerals, such as iron, zinc, and calcium.
Using the following guidelines can help to ensure
that the nutrient needs after 6 months of life of
the breastfed child are met:
-
Continue
to breastfeed as often as the infant desires.
-
Aim
for a variety of complementary foods, with fruits,
vegetables, and animal products (e.g., meat, fish,
poultry, or eggs) offered daily.
-
Iron-fortified
cereals and meats can provide adequate iron.
-
Calcium
can be obtained from cheese, yogurt, and other
dairy products (although fresh cow's milk is not
recommen-ded before 12 months).
-
Avoid
giving too much juice.
-
Be
alert to any signs that the child's appetite,
growth, or develop-ment is impaired.
-
When
in doubt, a balanced vitamin-mineral supplement
is advisable.
-
Make
mealtimes enjoyable.
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