Six months of exclusive breast feeding: how good is the evidence?
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.c5955 (Published 13 January 2011) Cite this as: BMJ 2011;342:c5955
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We have recently admitted 3 neonates
with dehydration, jaundice and weight loss of up to 20%. The babies were
admitted with dangerous levels of sodium between 157 and 163. All three
babies were exclusively breast fed.
UNICEF's 'Baby friendly Initiative' has published 10 steps to
successful breastfeeding including to "give newborn infants no food or
drink other than breast milk, unless medically indicated" and to "give no
artificial teats or dummies to breastfeeding infants"(1). However,
neither WHO nor UNICEF offer much advice on what mothers can do if
breastfeeding is not going as planned. Cup feeds are only briefly
mentioned in the extensive strategy documentation(2). The list of
acceptable medical reasons for use of breast milk substitutes does not
include dehydration or weight loss(3).
WHO strategy states that "the vast majority of mothers can and should
breastfeed"(2). However, studies have shown that few women achieve the
international recommendations for breastfeeding(4). It is possible that
unrealistic expectations are placed on mothers, so much so that mothers
may continue to pursue breastfeeding to the detriment of their baby's
health. This problem was highlighted in the Archives of Disease in
Childhood a few years ago(5,6) but the issue has become even more
pertinent given the current climate.
No doubt 'breast is best' but in our view, a blinkered rigid approach
to feeding newborns can lead to disastrous consequences for some children.
A balance needs to be struck between the pursuit of UNICEF targets for
exclusive breastfeeding by all mothers, and the individual needs of every
baby. We appreciate all of the advantages of breastfeeding and this letter
certainly does not set out to challenge or undermine that. But if babies
are not getting adequate hydration with exclusive breastfeeding, is it so
wrong to supplement with top-up feeds while continuing to establish
breastfeeds?
Dr. Stephen Nirmal, Consultant Paediatrician
Dr. Rachel Hutchinson, FY1 in Paediatrics
1. UNICEF UK. Ten Steps to Successful Breastfeeding.
http://www.unicef.org.uk/BabyFriendly/Health-Professionals/Going-Baby-
Friendly/Maternity/Ten-Steps-to-Successful-Breastfeeding/ (Accessed 9th
Oct 2011)
2. WHO/UNICEF. Global Strategy for Infant and Young Child Feeding.
World Health Organisation, Geneva, 2003
3. WHO. Infant and young child feeding. World Health Organisation,
Geneva, 2009. Available at;
http://whqlibdoc.who.int/publications/2009/9789241597494_eng.pdf
4. Scott J, Binns C, Oddy W, Graham K. Predictors of breastfeeding
duration: Evidence from a cohort study. Pediatrics 2006;117:646-655 (doi:
10.1542/peds.2005-1991)
5. Fawke J, Whitehouse W, Kudumula V. Monitoring of newborn weight,
breastfeeding and severe neurological sequelae secondary to dehydration.
Arch Dis Child 2008;93:264-265 (doi:10.1136/adc.2007.131136)
6. Leven L, Macdonald P. Reducing the incidence of neonatal
hypernatraemic dehydration. Arch Dis Child 2008;93:811
(doi:10.1136/adc.2008.143370)
Competing interests: No competing interests
I fully support exclusive breastfeeding for six months in developing
countries as the authors suggested. Six months exclusive breastfeeding has
been associated with the reduction of colic diseases, allergies and
decreased rates of infections. This article highlights some important
health benefits of exclusive breastfeeding, as well as challenging some of
the current views.
In my country, the issue of six months exclusive breastfeeding is faced
with certain cultural challenges which may add a new perspective to the
study.
Young mothers in some African cultures may experience pressure from older
family members to ensure their babies are getting enough nutrition by
introducing solids early. It is believed that a crying baby is evidence of
a reduced maternal milk supply. An older family member will force the
breastfeeding mother to introduce solids early to their babies, as it
believed that this will soothe the baby and provide better nutrition. Some
mothers have minimum milk supply than other breastfeeding mothers which
can be frustrating as this may result in the baby not receiving enough
nutrition. An indication of this is a crying baby. Working mothers are
facing a challenge of compressing milk daily for their babies and if they
are not motivated about benefits of breast milk, the care giver or an
older member of the family at home would introduce solids early.
Sincerely
Vellem
nonceba.vellem@gmail.com
Competing interests: No competing interests
I have no view on whether infants are better nourished via
introducing solids at four or at six months, but I am bemused at the BMJ's
publication of Fewtrell et al's paper.
Addressing a patently bio-psycho-social topic from a purely
biological perspective, Fewtrell et al refute weak evidence for a move to
6 months' EBF with equally weak evidence for a return to four.
It is hard to see the scientific point of a publication concluding so
much on the basis of so little in so politically and commercially
sensitive an area.
Competing interests: No competing interests
The article "Lactation wars" (BMJ 2011; 342:d835) by Christopher
Martyn (associate editor of the BMJ) includes the following:
"Mind you, some of the rapid responses on bmj.com weren't much
better. I won't give examples because they're only a click away, and you
can form your own view. The charitable explanation is that these
correspondents didn't really mean what they said, which is always a danger
when the heat of the moment coincides with the availability of instant
communication. I'd like to see "rapid responses" axed and replaced with
"considered responses." This new section wouldn't allow comments for at
least a week after the article was published, and there would be a cooling
-off period between submission and publication. Anyone sending something
in would have to confirm, 48 hours after they first sent it, that they
really did want it posted."
As one of those rapid response correspondents on bmj.com, I would
like to assure Christopher Martyn that I really did mean what I said, and
that today, almost four weeks after I submitted that initial response, I
do still want it posted.
I am surprised that an associate editor of the BMJ would appear in
print to express such contempt for rapid responders (who are by definition
among the journal's readership). Could it be that some of those responses
- particularly those that questioned the BMJ's decision to publish this
article in the first place - touched an editorial nerve?
Or perhaps Christopher Martyn didn't really mean what he said and
should have allowed himself a cooling-off period?
Competing interests: No competing interests
Fewtrell et al have provoked a storm of indignation by their
suggestion that UK health authorities review the current policy on
starting solids and consider returning to a guideline to start between 4
and 6 months rather than the 6 months currently recommended (1). The 6-
month guideline is being hotly defended on the grounds that this is the
one recommended by the WHO's systematic review of the subject, but this is
misleading; the actual finding of the WHO review was that, for infants in
the developed world, there is not a great deal of difference between the
two guidelines.
Nearly all of the wide range of outcomes examined in the WHO review
were unaffected by whether infants started solids at six months or during
the preceeding couple of months. One study in the developing world (3)
found increased rates of respiratory infection in breastfed infants who
started solids earlier, but this was not found in infants in the developed
world (4). Another study found increased rates of eczema in the earlier
starters (5), but in this study the 'early starters' started at three
months, not four, and the findings were not replicated in the PROBIT trial
(4). Therefore, the only finding likely to be of relevance to
consideration of the effects of a 4 - 6-month guideline on infants in the
developed world is the increased rate of gastroenteritis in the infants
who started solids earlier than six months (4). While this rate was high
in the developing world (3), in the PROBIT trial it approximated to a 1 in
41 chance of gastroenteritis from starting mixed feeding between three and
six months, which may well overestimate possible adverse effects of a 4 -
6-month guideline since it will have included infants who started solids
between three and four months. Rates of hospitalisation for
gastroenteritis showed no statistically significant difference. Finally,
follow-up of the PROBIT study at 6.5 years found no long-term differences
between the earlier starters and the later starters (6).
The available evidence therefore suggests that the benefit of waiting
a full 6 months to start solids rather than starting them between 4 and 6
months is small and short-term at best. While I am quite happy to advise
parents that delaying solids until six months may slightly reduce the risk
of tummy bugs and thus it is worth aiming to do so if possible, I do feel
it is important to keep the matter in perspective. The furore in response
to Fewtrell et al's paper is out of all proportion to what the evidence
actually shows. We need to consider what effect this may be having on
parents who may be left unnecessarily concerned about the possible effects
on their infants of having started solids earlier than advised by the
current guidelines, as well as on parents who are currently facing the
decision as to when to start solids and need accurate information on which
to base this decision.
It is important to remember that health policies are not implemented
in a vacuum; they have practical implications for the lives of those
attempting to follow them. While these can be beneficial (it is worth
noting that the effects of later introduction of solids also include
greater ease of introduction, delayed resumption of maternal menses, and
slightly faster weight loss for the mother), there can also be
considerable potential difficulties in maintaining exclusivity of
breastfeeding for a full six months, especially for women returning to
work before this time. Mothers need to be able to weigh any such
drawbacks against the benefits of exclusive breastfeeding over mixed
breastfeeding. To do this, they need accurate information. Let's be
honest about what the evidence actually does show in terms of benefit or
lack thereof, and let parents make a fully informed choice for themselves
as to whether or not they find those two extra months of avoiding solids
or formula supplements worthwhile.
(1) Fewtrell M, Wilson DC, Booth I, Lucas A. Six months of exclusive
breast feeding: how good is the evidence? BMJ 2011; 342:c5955
(2) Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding.
Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD003517.
DOI: 10.1002/14651858.CD003517.
(3) Khadivzadeh T, Parsai S. Effect of exclusive breastfeeding and
complementary feeding on infant growth and morbidity. East Mediterr
Health J 2004; 10(3): 289 - 94.
(4) Kramer MS, Guo T, Platt RW, Sevkovskaya Z, Dzikovich I, Collet
JP, et al. Infant growth and health outcomes associated with 3 compared
with 6 months of exclusive breastfeeding. Am J Clin Nutr 2003;78:291-5.
(5) Kajosaari M, Saarinen UM. Prophylaxis of atopic disease by six
months' total solid food elimination. Evaluation of 135 exclusively
breast-fed infants of atopic families. Acta Paediatr Scand 1983; 72: 411
- 4.
(6) Kramer MS, Matush L, Bogdanovich N, Aboud F, Mazer B, Fombonne E.
Health and development outcomes in 6.5-y-old children breastfed
exclusively for 3 or 6 mo. Am J Clin Nutr 2009; 90(4): 1070-4.
Competing interests: No competing financial interests. SCV breastfed both children successfully by expressing milk after returning to work, but had to supplement her first child with solids and formula from four months onwards.
It seems extraordinary that concern about possible effects on iron
deficiency and coeliac disease should lead the authors of this review to
suggest shortening the recommended duration of exclusive breast feeding
(EBF), when they themselves acknowledge that longer durations of EBF are
associated with substantial reductions in infectious diseases. There is
now excellent research evidence that this applies to children in affluent
as well as deprived societies.(1;2). Visit any UK paediatric ward and you
will find them teeming with infants with infections, not iron deficiency
and coeliac disease. It is inevitable that there will be harms as well as
benefits associated with deferring solids and the WHO determined the age
at which equipoise between the two was reached.
It also seems extraordinary that the BMJ would publish this highly
subjective article in the same issue in which they repeatedly castigated
the Lancet for its behaviour in relation to MMR. Many children will lose
the protective benefit of breast milk as result of their inflammatory
publcity and become ill as a result. Will the BMJ next mount an expose of
its own irresponsibility?
(1) Wright CM, Parkinson K, Scott J. Breast-feeding in a UK urban
context: who breast-feeds, for how long and does it matter? Public Health
Nutr 2006; 9(6):686-691.
(2) Ladomenou F, Moschandreas J, Kafatos A, Tselentis Y, Galanakis E.
Protective effect of exclusive breastfeeding against infections during
infancy: a prospective study. Arch Dis Child 2010; 95(12):1004-1008.
Competing interests: No competing interests
In their recent review Fewtrell et al. suggest that exclusive
breastfeeding to 6 months could increase risk of anaemia. In view of this
we would like to share some of our preliminary findings from a study
currently being conducted in Brighton.
We are exploring the feeding practices and iron status of infants
breastfed for at least six months. Most of these infants also conformed to
the Government's recommendation to delay introducing solid foods until
around 6 months and all were exclusively breastfed until at least 4
months. Even though our sample size was small, we found consistent
evidence that in this group dietary iron intakes at 8 months were very
low, with mean total iron intakes from all foods and drinks including
breast milk being less than half the currently recommended levels (1). A
sizeable proportion of participants actively avoided giving their children
foods rich in bioavailable iron such as red meat. We found no evidence of
low haemoglobin levels with all haemoglobin measurements being well within
the normal range for this age group, as described by Emond et al (2).
It appears that despite low dietary iron intakes, haemoglobin levels
are maintained at least until 8 months of age in this group of infants.
Possible explanations for this may include sufficient iron endowment
prenatally (in terms of maternal health and nutrition) and perinatal
factors such as variations in cord clamping practices (3) or a possible
over estimation of iron requirements in the 6-9 month age group.
Publication of the results will follow shortly.
1.COMA (1991). Dietary Reference Values for Food Energy and Nutrients
for the United Kingdom, Report on health and social subjects, No. 41,
HMSO. London
2.Emond, A. M., Hawkins N., et al. (1996). Haemoglobin and ferritin
concentrations in infants at 8 months of age. Arch Dis Child 74 (1): 36-9
3.Chaparro, C.M., Neufeld L.M., Tena et al. (2006). Effect of timing
of umbilical cord clamping on iron status in Mexican infants: a randomised
controlled trial. Lancet 367: 1997-2004
Competing interests: P. Emmett has received small amounts of research funding from two companies manufacturing infant formula and infant foods in the past three years.H. Rabe is the first author of the Cochrane Review on early versus slight delay of cord clamping in preterm infants.
I strongly second the concerns of Mahendradhata et al , (1) that in
developing countries this article is likely to be misrepresented to the
advantage of infant milk substitute and weaning food manufacturers ,
cause confusion to lay people as well as grass root health personnel.
The article clearly debates the optimal duration of exclusive breast
feeding in the European countries/ U.K/ developed countries and endorses
that "Exclusive breast feeding for six months is readily defendable in
resource poor countries".
However this emphasis in the article is neither reflected in the
title of the article nor highlighted in the text/ summary boxes.
Given the wide readership of the BMJ and the large influence that its
publications have on health practice throughout the world I feel that the
editorial board and reviewers need to keep in mind their social
responsibility, to the world, that publications are edited also to
emphasize their exact scope and avoid /minimize possible
misinterpretation / misrepresentation internationally.
Reference:
1.Mahendradhata, Y H, Mahendradhata Y. Analysis of the evidence for six-
months of exclusive breastfeeding: the good, the bad and the ugly Rapid
Respons to Fewtrell, M, Wilson, David C , Booth I, Lucas A. Six months
of exclusive breast feeding: how good is the evidence? BMJ 2011; 342:c5955
Competing interests: No competing interests
La Leche League has been providing breastfeeding information and
support to parents for over fifty years. We support the view of The World
Health Organisation (WHO), The Department of Health (DH), and other
eminent organisations, that infants should be exclusively breastfed for
around the first six months of life to achieve optimal growth, development
and health. Thereafter, to meet their evolving nutritional requirements,
infants should receive appropriate complementary foods alongside continued
breastfeeding.
When WHO recommended this policy it was based on a systematic review
of 3,000 studies on infant feeding. The article the British Medical
Journal published, on 14 January 2011, suggesting that babies need solids
earlier than six months of age, is not a new research study or a
systematic review of all available evidence. Three of the four authors of
this research have declared an association with the baby feeding industry.
There is clear scientific evidence that breastfeeding protects both
the short and long term health of mothers and babies. It reduces the risk
of infections such as gastroenteritis and respiratory, ear and urinary
tract infections, particularly infections requiring hospitalisation, even
in developed countries such as the UK. The risk of diabetes and obesity
in children and cancer in mothers is lessened and it reduces the risk of
postnatal depression and neglect. With the current risk of swine flu,
exclusive breastfeeding reduces the risk of the baby catching secondary
infections, which could be serious enough to need hospital admission.
* The BMJ article says that delaying introducing solid food may
increase the risk of iron deficiency anaemia (IDA)
Breastmilk supplies all the essential nutrients a baby needs for
around the first six months of life. There isn't a lot of iron in
breastmilk because there isn't supposed to be. It is more completely
absorbed by a baby than the kind in formula, baby cereal or supplements.
Breastmilk contains a protein that binds to any extra iron that the baby
doesn't use because too much iron can end up feeding the wrong kind of
bacteria in his intestines and this can result in diarrhoea/constipation
or even microscopic bleeding. Formula fed babies can have too much iron in
their intestines, which causes these problems and ends up reducing their
overall iron.
If a baby is started on solids before he is ready iron stores can
drop. Some fruits and vegetables can bind with iron before the baby has a
chance to use it. These foods are often low in iron and so are simply
replacing the perfect food for babies with ones with fewer nutrients.
To help ensure a breastfed baby has a good supply of iron, women can
look at their diet during pregnancy and ask that the umbilical cord is not
cut before it stops pulsating as this adds to his iron supply.
* The BMJ article says that delaying introducing solids may increase
the risk of coeliac disease
Coeliac disease is associated with the early introduction of gluten,
which is found in cereals. Currently available evidence on the timing of
the introduction of gluten into the infant diet is insufficient to support
any recommendations and a study suggesting this should be at four months
is considered by many to be flawed. There is evidence suggesting that not
being breastfed at the time gluten is introduced into the diet is
associated with an increased risk of subsequently developing coeliac
disease.
* The article says that delaying introducing solids may increase food
allergies
A baby's insides are designed to be ready for solid food once his
outside has developed enough for him to eat it on his own. If offered too
soon he will automatically thrust it back out to protect his digestive
tract. La Leche League suggests mothers look for cues that their baby is
ready, such as being able to sit up, pick up food, get it in his mouth and
chew without choking, and that often happens around six months. A baby's
digestive tract needs to be mature before starting solids so the lining of
his intestines is sealed against allergens (allergy producers). If given
solids too early allergens can slip through the intestinal wall into the
blood stream and the baby produces antibodies against them, which can
result in allergies such as eczema.
At around six months a baby starts producing adult-type enzymes,
which we need to break down food for digestion. If he has solids before
he can digest them properly it can cause tummy problems and the nutrients
will not be fully utilised.
Trials are being undertaken to test if babies with a family history
of true allergy might be helped by earlier introduction of certain foods
but, as a rule, the majority of babies are less likely to have an allergic
reaction to foods by around six months.
* The article suggests that introducing new tastes at an earlier age
may increase acceptance of leafy green vegetables and encourage healthy
eating later in life
This is purely speculative. Breastmilk prepares a baby for family
food as it changes in flavour depending on the mother's diet and so
exposes the baby to various tastes from birth on wards. In fact research
shows that formula-fed babies often don't accept new tastes as willingly
as breastfed babies. What a baby prefers to eat will be dependent on many
things and will change as he grows. Some mothers have found that if a
baby was encouraged to eat a food he had shown a particular aversion to it
caused a negative reaction, perhaps showing that babies instinctively know
what to refuse. If offered a range of healthy foods babies tend to take
what they need.
* The article says that delayed introduction to solid foods may be
linked to increased obesity
This is in total conflict with the studies showing that early
introduction, particularly of sugary foods, is an important factor behind
the obesity epidemic and can lead to babies being overfed. Breastfeeding
helps a baby to regulate his own appetite so that when he starts solids he
may be better able to avoid over eating.
La Leche League GB knows that women already receive conflicting
advice and information on many aspects of childcare and that this report
has caused concern and confusion amongst parents wondering what to do for
the best for their children. Babies' individual development varies and
parents are best placed to look for signs that their baby may be ready for
solid food, around six months of age.
While we recognise that it is important to ensure that
recommendations are based on the best available evidence, and are
regularly reviewed, we continue to believe that breastmilk provides
everything a baby needs up to around six months of age and that to
introduce other foods before a baby is ready is not beneficial.
Competing interests: No competing interests
Re: Six months of exclusive breast feeding: how good is the evidence?
Sudden Unexpected Postnatal Collapse is a condition in which a previously vigorous, spontaneously breathing infant who had a five-minute Apgar of 8 or more, unexpectedly becomes apneic, often necessitating full resuscitation(1). Sudden collapse has also been defined as acute cyanosis/pallor and unconsciousness, requiring bagging, intubation and/or cardiac compressions and has been found to commonly occur with breastfeeding of the newborn(1).
Estimated incidence of the SUPC of a presumably healthy infant after birth differs widely, ranging from 2.6 cases to 133 cases/100,000(2).
SUPC in apparent healthy babies is associated with initial, unsupervised breastfeeding, prone position, primiparity and distractions. Guidelines outlining the appropriate monitoring of newborns and safe early skin-to-skin contact should be implemented(3). The assessment tool is called the Respiratory, Activity, Perfusion, and Position tool (RAPP. The Medscape emphasizes need to monitor RAPP(1).
Components of a safe positioning checklist should include the following (1):
Mother or provider of SSC is in reclining position, not flat
Infant's back is covered and hair is dry
Infant is well-flexed on provider's chest
Infant's shoulders are flat against provider's chest
Infant is chest-to-chest with provider, not over a breast
Infant's head is turned to one side
Infant's face can be seen
Infant's nose and mouth are visible and uncovered
Infant's neck is straight, not bent
References:
1. http://www.medscape.com/viewarticle/822017_2
2. Herlenius E, Kuhn P. Sudden unexpected postnatal collapse of newborn infants:
a review of cases, definitions, risks, and preventive measures. Transl Stroke
Res. 2013 Apr;4(2):236-47. doi: 10.1007/s12975-013-0255-4. Epub 2013 Feb 23.
3. Pejovic NJ, Herlenius E. Unexpected collapse of healthy newborn infants: risk
factors, supervision and hypothermia treatment. Acta Paediatr. 2013
Jul;102(7):680-8. doi: 10.1111/apa.12244. Epub 2013 Apr 30.
Competing interests: No competing interests