Analysis

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

La Leche League GB's response to the article reported in the British Medical Journal, January2011, questioning the recommendation to introduce solid food to babies at 6 months

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

27 January 2011
Anna D Burbidge
Chair, Council of Directors
La Leche League GB