Breast feeding
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39521.566296.BE (Published 17 April 2008) Cite this as: BMJ 2008;336:881
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There is a danger that the recommendation of exclusive breast feeding up to six months will become an unworkable dogma. The WHO guidelines do point out the danger of growth faltering and iron and micronutrient deficiencies in with exclusive breast feeding in a minority of cases but the authors do not cover this adequately. Researchers have pointed out that breast milk may not be sufficiently energy dense to sustain normal growth. This would become critical at 58 kcal/100 ml, which is a commonly reported value for human breast milk (Morgan JB, Dickerson JWT. Nutrition in Early Life. Publisher: John Wiley & Sons, Chichester, England). The paper quoted by the authors to justify adoption of the WHO growth chart rather than the 1990 UK growth chart still shows growth faltering in 2-3% of infants at age 4 months (Wright C, Laksham R, Emmett P, Ong K. Implications of adopting the WHO 2006 child growth standard in the UK: two prospective cohort studies. Arch Dis Child; online 1 Oct 2007), however the authors concede that infants in their sample include a significant proportion (no figure given) who had supplemental feeds or solids both before and after 4 months. The authors are unable to quote data on the incidence of growth faltering with exclusive breast feeding. This data does not exist? Most mothers will know when their 3-4 month infant is hungry despite adequate breast-feeding. The next problem is to ensure that they are given the correct advice on starting supplementary solids (preferable to formula milk?) and this issue has not been addressed.
Competing interests: None declared
Competing interests: No competing interests
The clinical review on breast feeding misses the most important issue: smoking.1 The few smoking mothers who are breastfeeding rapidly abandon it while their disadvantaged premature children are those who can most benefit of the protection afforded by breastfeeding.2 Indeed, smoking is strongly associated with preterm delivery (with a dose-response effect, ie adjusted ORs = 2.46 for >10 cigarettes/day).3
Depending on socio-economic factors, between 11% and 20% of all pregnant women in the United States smoke and the dramatic rise in smoking rates in developing countries is well known. Nice’s guidance also ignore this target.4
Clinicians must screen all pregnant women for tobacco use and provide augmented pregnancy tailored counselling to those who smoke. Thed benefit for infants in rich and poor countries is similar.
1 Hoddinott P, Tappin D, Wright C. Breast feeding. BMJ 2008;336:881-7
2 Dorea JG. Maternal smoking and infant feeding: breastfeeding is better and safer. Matern Child Health J. 2007; 11:287-91.
3 Nabet C, Lelong N, Ancel PY, Saurel-Cubizolles MJ, Kaminski M. Smoking during pregnancy according to obstetric complications and parity: results of the EUROPOP study. Eur J Epidemiol 2007 Aug 29; (Epub ahead of print ).
4 www.nice.org.uk/page.aspx?o=346169
Competing interests: None declared
Competing interests: No competing interests
As an experienced health visitor who works in a PCT where encouraging mothers to breastfeed is seen as priority , and where the majority of mothers I see breastfeed, I read with interest the Clinical Review of Breastfeeding. However, I am concerned about the authors’ uncritical approach to the WHO recommendation that mothers should breastfeed exclusively for six months. Of course mothers should be encouraged to exclusively breastfeed for 6 months if possible, but, as Foote and Marriott have stated(1): this is a one size fits all approach to weaning that may not take sufficient account of the special needs of some infants. Also, as the UK recommendations state these are guidelines only, and need to take into account the needs of individual infants.
In my experience this may indicate a need for introduction of complementary foods as early as 4 -5 months of age, for instance if a baby of five month who was sleeping through the night wakes up and starts demanding several breastfeeds, leaving the mother feeling exhausted. I am also seeing (mainly professional) mothers who will confess that they have already started solids because they felt their five month baby was hungry and needed more food. In these cases I feel it is better to advise about the correct foods that should be introduced for early weaning rather than quote rigid WHO recommendations which they are likely to ignore. Only this week too I saw a 3 month old breastfeeding baby who was suffering from severe reflux, and whose mother had been advised by a hospital paediatrician to start solids at 4 months. My reaction was 3 cheers for common sense (especially as this was the advice I would have given). I find paediatricians also recommend premature babies start solids before 6 months. In my experience too, if mothers are adamant that they want to start introducing formula at 4-5 months for various reasons, I find being relaxed rather than inflexible about introducing solids and advising some fruit and veg instead, encourages them to continue breastfeeding rather than changing to formula. Finally, although introducing solids before 4 months is not something, as a health visitor, I would recommend, to quote the Editor in Chief of Archives of Disease in Childhood (2): ‘How we interpret the (weaning) data for parents is complicated. Most of the parents I know (including my friends and colleagues who are paediatricians) introduce solids by 3–4 months’ 1Foote KD, Marriott LD. Weaning of infants. Archives of Disease in Childhood 2003, 88: 488-492 2 Bauchner Howard. Atoms. Archives of Disease in Childhood 2004;89:295
Competing interests: None declared
Competing interests: No competing interests
I have personal experience with breastfeeding a baby for 6 months. I have to say that the amount of written information that was heaped on me during my pregnancy contrasted sorely with the lack of any useful advice given by most midwives and lactation experts.
I also met other breastfeeding women regularly, all of them trying very hard, with varying success, and this is what I learned: Every woman is different, every breast, every nipple is different and every baby is different. One or two techniques (and that's all the advice you are ever given) don't cover all. Many women have difficult nipples, and nobody looks at them before the baby is born. Many are dreaming of the day the baby will sleep through the night (won't happen as long as you feed exclusively!). Some feel rejected by a non-feeding baby, some feel very guilty if things don't work and they have to give up. Some even have too much milk, soaking their beds and clothes and making their babies choke and produce grass-green poo!(the latter don't get much empathy from the women with too little milk).
I believe one-on-one advice should be given in a hands-on fashion, maybe using a doll, on the actual breasts of the mother, possibly before the baby is born. And only by a woman who has been through this herself. Since our mothers probably have no experience, we might have to pay women who do. And stop making mothers feel guilty. They are trying very hard.
Competing interests: None declared
Competing interests: No competing interests
As I was reading the clinical review on breast feeding my ten week old baby was having his third breast feed of the day.
The article was excellent but I was surprised at the NICE and Cochrane conclusions that length of hospital stay does not influence the duration of breastfeeding, especially as the greatest decline in breast feeding occurs within the first few weeks.
Early discharge from hospital is often encouraged but if breast feeding is to be continued beyond the first few weeks it is essential that the NHS provides women throughout Britain with 24 hour access to breast feeding support and advice from fully trained staff.
I was lucky to have my baby in an area with an excellent community midwifery service which despite recent staff shortages aimed to give each woman support with breast feeding. This included a 24 hour helpline and daily hour-long 'masterclasses' in breastfeeding for the first ten days as part of the home visit. If this had not been the case I certainly would have changed to bottle feeding within the first week, despite knowing the multiple benefits of breast feeding.
It can be a very lonely place in the middle of the night with a newborn baby who cannot feed and when every feed is difficult and painful. In hospital women are supported and helped through this by trained midwives and assistants no matter what time of day, however once at home giving a bottle of formula feed is often seen as quick and easy solution to the problem.
Without well funded and fully staffed community midwifery services no amount of health promotion and education will replace hospital care in preventing desperate new mothers reaching for the bottle.
Competing interests: LA is currently breastfeeding her baby.
Competing interests: No competing interests
Important implications for policy choices
That both the Hoddinott et al. and MacArthur et al. randomized trails find no significant changes in breastfeeding rates has important policy implications. These results contrast sharply with the recent recommendation by the USPSTF (p. 560), based on the assessment based on meta analysis, that "there is moderate certainty that interventions to promote and support breastfeeding have a moderate benefit." If these two relatively large trails had been included in the meta analysis, the estimated impacts might have been less or insignificant. In any case these two studies cast doubt on whether the benefit-to-cost ratios for public resources devoted to improving infant nutrition are likely to be sufficiently high for policies to promote breast feeding of the types examined in these studies.
U.S. Preventive Services Task Force, “Primary Care Interventions to Promote Breastfeeding: U.S. Preventive Services Task Force Recommendation Statement,” Annals of Internal Medicine Volume 149:8 (21 October 2008), 560-565.
No competing interests.
Competing interests: None declared
Competing interests: No competing interests