In brief
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7297.1266 (Published 26 May 2001) Cite this as: BMJ 2001;322:1266
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Global Strategy for infant and young child feeding (2 July 2001 Julie
Lanigan)
Sir,
The comments on WHO current recommendations for infant feeding practices
by Julie Manigan are merely individualized concern.
Firstly it should be clear that since long time “4-6 months” is considered
an outdated terminology. This phrase, in the Innocenti Declaration of
1990, predates the evolution of knowledge about damaging effects of early
complementation upon both breastmilk intake and infant morbidity. In 1993
UNICEF publications recommended as follows: “Breastmilk alone is the best
possible food and drink for a baby. No other food or drink is needed for
about six months of life.” (Facts for life UNICEF 1993)
In 1994 WHA resolution 47.5 recommends: “fostering appropriate
complementary feeding practices from the age of about six months.”
In 1999 UNICEF publication repeated the recommendation: “Babies should be
exclusively breastfed-meaning that they receive nothing but breastmilk,
not even water for about the first six months of life.” (Breastfeeding:
foundation for a healthy future. UNICEF 1999)
Secondly early weaning has not been reported to have any clear advantage
even in Low Birth Weight infants. The work of Dewey, Cohen et al in
Honduras indicates that no growth advantages is seen in Low Birth Weight
infants when complementary foods are introduced before six months (1).
Thirdly breastmilk is the only “standard food” for the human infant with
complete and perfectly balanced mixture of all required nutrients. The
mentioning in the letter “such recommendations could lead to an increase
in sub-clinical deficiencies of iron and zinc” is not based on any factual
and scientific knowledge. Indeed, healthy infants born at term to well-
nourished mothers have sufficient hepatic stores to meet their needs for
the better part of the first year (2). Early introduction of other foods
in the diet of the breastfed infants can alter the picture (3). Even
supplemental iron may cause problems by saturating Lactoferrin, decreasing
it’s bacteriostatic effect which may cause gut damage and microscopic
bleeding to produce iron-deficiency anemia (4). Moreover, it is important
to mention that up to 70% of breastmilk iron is absorbed, compared with
30% in cow’s milk and only 10% in breast-milk substitutes (5). The amount
of Zinc in human milk is small but sufficient to meet the needs of infants
and it’s bioavailability is high compared with Zinc added to breastmilk-
subtitutes. Also high Zinc: Copper ratios have been associated with
coronary heart disease (6).
Fourthly risks of the early complementary feeding must be emphasized. The
short-term risks include decrease in the frequency and intensity of
sucking and as a consequence breastmilk production also decreases, the
cereals and vegetables can interfere with the absorption of breastmilk
iron (7) and the greatest immediate risk in developing countries is
diarrhoeal disease (8). Early complementary feeding practices may also
have a negative impact on health in the long term like obesity,
hypertension, arteriosclerosis, and food allergy (9)(10).
Lastly any research sponsored by industry must be viewed with a lot of
caution as oftenly industry funding influences the design of the protocol
and the questions that are asked by the researchers to avoid unfavourable
results. In short the funding would definitely influence the research
reports and not a single research study funded by company has been
observed with results opposite to their desired intention.
In view of above the age of six months for introduction of complementary
foods is most appropriate in regards to breastfeeding, health and growth
of the children.
DR.KHALID IQBAL TAHIR
Neonatal Intensive Care Unit,
Maternity and Children Hospital,
Madina Al-Munawarah,
SAUDI ARABIA.
Email: kitfeed@yahoo.com
References:
1. Dewey, Cohen et al Am J clin Nutr (1999; 69[4])
2. Picciano, M.F. Trace elements in human milk, New York, Raven Press,
1985, pp157-174.
3. Oski, F.A. Inhibition of iron absorption from human milk by baby food.
Am j dis child 134: 159-160(1980).
4. Oski, F.A. is bovine milk a health hazard? Pediatrics, 75:182-
186(1985).
5. Saarinen, U.M. Iron absorption from breastmilk cow’s milk and iron-
supplemented formula. Pediatrics, 13:143-147(1979).
6. WHO BULLETIN, Vol. 67, 2:30 (1989).
7. Oski F.A. Development of the small intestine’s capacity to absorb
iron. Textbook of Gastroenterology and Nutrition in infancy, Vol.1. New
York, Raven Press. 1981, p, 612.
8. Gordon, J.E. et al Weaning diarrhoea, Am. J. med. Sci. 245: 345
-377(1963).
9. Eid, E.E. Follow up study of physical growth of children who had
excessive weight gain in first six months of life. Br. Med. J., 2:74-76
(1985).
10. Kayosari, M. & Saaren, V. Prophylaxis of atopic disease by six
months’ total solid food elimination. Acta Paeditr. Scand., 72: 411-414
(1983).
Competing interests: No competing interests
Sir,
We are writing to express concern regarding the events that have
unfolded since the publication of a press release by the World Health
Organization (WHO) on 2 April which announced the results of deliberations
of a panel of experts, commissioned by WHO to examine current
recommendations for infant feeding practices (BMJ, 26 May, p1266). The
Expert Consultation recommended exclusive breastfeeding for 6 months, with
introduction of complementary foods and continued breastfeeding
thereafter, a change from the previous recommendation to breastfeed
exclusively for 4-6 months (WHO, 1995). Our interpretation of the press
release was that its contents should not be viewed as a change in the
WHO's own stance on the age of introduction of complementary foods to the
full-term infant, but should be seen as a document which would stimulate
further discussion and research. Furthermore the 1995 recommendations
(WHO, 1995) still stand as current WHO policy; if these documents are
scrutinised it is clear that flexibility in recommendations is still
central to WHO's strategy. Subsequently, at the recent fifty-fourth World
Health Assembly (WHA) in May this year, it was reported that the WHA
undertook to take serious consideration of the Expert Consultation's
recommendations (World Health Assembly resolution 54.2).
As authors of a recently published systematic review concerning the
age of introduction of complementary foods to the healthy full-term infant
(Lanigan et al, 2001), we were surprised that the WHO expert consultation
considered current scientific evidence provided adequate data on which to
recommend a change. Our own review reported that out of 33 studies
meeting inclusion criteria, 13 contained data supporting the current WHO
recommendations and an equal number contained data supporting a
recommendation for exclusive breast-feeding to six months. This review
also assessed the methodological quality of current scientific evidence
and concluded that there is a lack of clear evidence to either support or
refute a change to the current recommendations.
The 1995 WHO recommendations advised introduction of complementary
foods between 4 and 6 months of age denoting an age range that was
considered appropriate to allow a transitional period for the breast fed
infant to adjust to solid food intake (Akre, 1989). The WHO systematic
review, in common with ours, acknowledged the existence of sub-groups of
infants for whom exclusive breast-feeding for 6 months could not support
adequate growth or nutritional status and an age range would therefore
accommodate these sub-groups. In terms of morbidity, there is some
evidence in less developed settings for a protective effect of exclusive
breast-feeding for 6 months against gastrointestinal infections. However,
such a recommendation could prove detrimental leading to an increase in
sub-clinical deficiencies of micronutrients such as iron and zinc and
these may have a greater impact in more developed societies where
diarrhoeal disease does not have such serious implications for long term
health and survival. Clearly what emerges is the need for a risk-benefit
analysis regarding the appropriate timing of complementary feeding
depending on the specific population. Moreover, it is important to
remember that health care professionals have the task of guiding mothers
of breast-fed infants in best infant feeding practice and the structure of
the revised global strategy does not provide clear and unambiguous
guidance.
In view of these real concerns and the possibility of a roller-
coaster effect overtaking proper and reasoned arguments, grounded in
evidenced-based research, we ask that any consideration, by the WHO or
other national and international bodies, of changes to current
recommendations is undertaken with prudence and caution.
Julie Lanigan*, Research assistant
Jane Morgan, Reader in Childhood Nutrition (corresponding author)
School of Biomedical and Life Sciences
University of Surrey, Guildford, Surrey GU2 7XH
Email j.morgan@surrey.ac.uk
Since the work for our review was partly funded by a grant from
Nestlé UK Ltd we are aware that some people will, for that reason, cast
doubt on our conclusions. However, we would like to make it clear that
source of funding has never influenced the conclusions drawn in this or
any of our publications.
* currently Trials co-ordinator at MRC-Childhood Nutrition Research
Centre, Inst, of Child Health, London
References
WHO recommends exclusive breast feeding for first six months. British
Medical Journal, 2001, 322: 1266
The World Health Organization's infant-feeding recommendation. Weekly
Epidemiological Record, 1995, 70: 119-120.
Systematic review concerning the age of introduction of complementary
foods to the healthy full-term infant. European Journal of Clinical
Nutrition, 2001, 55: 309-320.
Infant feeding: the physiological basis. Bulletin of the World Health
Organization. 1989, 67 (Suppl): 1-108.
Competing interests: No competing interests
Age of introduction of complementary foods
I agree with Lannigan and Morgan concerning the age of introduction
of complementary foods.
The current 4 - 6 month recommendations (rather than around 6 months)
are supported by a) all other consensus statements made by expert
committees covened by governments or professional societies (b) the
thousands of mothers who successfully and safely introduce other foods to
their babies before the age of 6 months (c) some (but not all) respected
nutritionists and paediatricians working in the field (d) many (but not
all) studies performed in both developing and developed countries( see
comments and paper by Lanigan, Morgan et al).
In my opinion it would be inappropriate to change the 4 - 6 month
recommendation now while there is only limited expert opinion,
scientific evidence or actual experience to do so.
I have received fees from WHO and many food companies for opinions
concerning child nutrition.This may be seen as a conflicting interest but
while appreciating Dr Tahir's carefully presented arguments I can think of
various publications where the observations did not favour the product of
a particular company, even though the company had supported the
investigation. My limited experience in Saudi Arabia suggested that the
late, rather than the early, introduction of complementary foods was a
factor in the very high prevalence of iron deficiency and rickets there .
Competing interests: No competing interests