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
All rapid responses
The good thing about the analysis by Fewtrell et al is that it
reminds us that it has been a decade since WHO recommended six-months of
exclusive breastfeeding and thus there is indeed a need to review the body
of evidences which has been growing since then (a quick search in PubMed
using the key word of "exclusive breastfeeding" revealed 860 publications
since 2001). The bad thing is Fewtrell et al offered a highly biased
'review' of the evidences, despite making a plea for an independent
scientific review. Previous posted responses have highlighted the
selective biases, speculative nature and vested interests of the authors.
The ugly part is what is may yet to come: the analysis could spur
tidal waves reaching shores of developing countries where thousands
infants are increasingly at risk of dying from infections partly due to
lagging adoption of the six-months exclusive breastfeeding recommendation.
Health workers in developing countries for the past decade have been
struggling to ensure babies are exclusively breastfed for six-months. Our
efforts have been severely hindered by public relation campaigns of multi-
national corporations producing infant formulas and baby foods, looking
for every single possibility to exploit a vast and rapidly growing market
of families with babies less than six months of age. To be fair, Fewtrell
et al stated that "exclusive breastfeeding for six months is readily
defendable in resource poor countries with high morbidity and mortality of
infections." This however is only one sentence consisted of 19 words,
drowned in the middle of an article consisted of over 2000 words which are
mainly geared toward questioning the validity of the six-months of
exclusive breastfeeding recommendation. The geographical extrapolation
caveat was also not reflected at all in the bold and provocative title of
The paper by Fewtrell et al has already received broad mass media
attention in Europe, in many cases inappropriately quoted as noted in
previous posted responses. It will just be a matter of time before this
reaches mass media in developing countries, highlighting only the
provocative points, leaving out counter arguments and other complex
details. Unfortunately, there is limited capacity in developing countries
to scrutinize such an eloquently written and high-profile article
published in a highly respected international medical journal. Fewtrell et
al thus have now given additional ammunition for public relations of
infant formulas and baby food corporations to launch a fresh attack on the
already battered health workers in developing countries. Our work has just
Competing interests: The authors are parents of six-months exclusively breastfed healthy children
Fewtrell and colleagues' analysis of breast-feeding guidance
demonstrates a strong clinician-centred rather than patient-centred focus
of the existing evidence base.
Further factors are relevant to the decisions made by mothers about how
long to breastfeed their baby and what techniques they use if they need to
return to work but also whether to try breastfeeding at all:
What is the mechanism behind gastroenteritis protection? Is it from
immune protection within the milk or does it relate to hygeine factors? Do
studies tell us if infection rates differ between babies fed expressed and
stored breast milk with those fed either directly from the breast or those
fed formula milk?
Has any assessment been made of the psychological burden on those
mothers that 'fail' to adhere to strict and specific guidelines?
One group of women - those that try hard but give up due to a wide variety
of reasons - may suffer lower self esteem and reduced parental confidence,
which may contribute to increased risk of postnatal depression and/ or
need for support from the primary health care team. A second group of
women simply do not try as the journey can seem too long and not worth
starting. Anecdotal reports suggest some midwives limit breastfeeding
support for mothers who choose to combine breast and bottle feeding as
they will not contribute to their local exclusive breastfeeding targets
and hence are not seen to be 'worth the effort'.
Shouting louder support for any breastfeeding initiations might help
develop a larger cohort of mothers who have given it a try and who may
then go on to breastfeed their subsequent babies for longer.
The best guidance should surely help women make an informed choice
based on a combination of the practicalities of their own circumstances
and practical guidance developed from a comprehensive evidence base. Where
that evidence base is unclear, dogmatic guidance may have some detrimental
Competing interests: I "failed" to exclusively feed any of my 3 children for more than 4 months, but they are all doing ok!
With high regard to your scientific experience and depth of your
research, may I humbly submit an observation based on some life
For many generations, maternal side of my family used a simple and
natural sign of babies' first teeth appearance as a guiding signal to
start introducing solids into their diets, along with continuing
breastfeeding (this was being stopped gradually, and lasted depending on
an individual child's demand for breast milk).
There never has been any serious trouble with those babies' digestive
systems and I had succesfully used this approach on both of my children,
with very good results.
Perhaps, a wider scientific research in this direction (possible
correlation between the naturally programmed first teeth growth and
babies' bodies need in solids) could be of benefit for the question in
I. Zhuravel-Wilcock, Mrs
Competing interests: No competing interests
If less than 1% of women manage to achieve 6 months of exclusive
breast feeding, despite government advice, something must be wrong.
Therefore Mary Fewtrell and colleagues are right to ask why this is so and
what lessons we have to learn from the last seven years. Perhaps the case
for exclusive breast feeding causing anaemia is not so strong and yet
there is a correlation in some studies other than the Lucas study that
they quote (1)(2). Angry responses to Fewtrell's analysis do not throw
much light on the subject. This paper does not make a case for topping up
with formula feeds after four months as some respondents have complained.
There is, however, a strong case for complementary feeding after four
months with carefully selected pureed foods, in very small quantities
initially. The argument that our stone-age ancestors managed without this
(and therefore exclusive feeding is natural and must be the norm) is
probably flawed. True, there was no power supply or blender in the stone-
age kitchen, but mothers have practiced premastication and transfer of
food to the baby's mouth throughout history. Many still do (3)(4). In 1967
the German Zoologist, Wolfgang Wickler, suggested that kissing did not
evolve, originally, as a courting ritual but was the method by which a
mother transferred premasticated food from her mouth to her infant's mouth
(5). This is the "natural" way to start complementary feeding from four
months onward. Formula milk is unnatural but I think that blending foods
and feeding them to our infants can be seen as a reasonable modern
alternative to premastication.
1) Ziegler EE, Nelson SE, Jeter JM (2009). Iron supplementation of
breastfed infants from an early age. American Journal of Clinical
(2) Dijkhuizen MA, Wieringa FT, West CE, Muherdiyantiningsih, Muhilal
(2001). Concurrent micronutrient deficiencies in lactating mothers and
their infants in Indonesia. American Journal of Clinical
(3) Imong SM, Jackson DA, Rungruengthanakit K, Wongsawasdii L,
Amatayakul K, Drewett RF, Baum JD (1995). Maternal behaviour and socio-
economic influences on the bacterial content of infant weaning foods in
rural northern Thailand. Journal of Tropical Pediatrics;41(4):234-40.
(4) Zhang Y (2007). The role of pre-mastication in the evolution of
complementary feeding strategies: a bio-cultural analysis. Honors Thesis
presented to the College of Agriculture and Life Sciences, Division of
Nutritional Sciences of Cornell University (Mentor: Gretel Pelto)
(5) W Wickler (1967). Socio-sexual signals and their intra-specific
imitation among primates. Primate ethology. In: Primate Ethology (D.
Morris ed.):69-147. Publisher: Weidenfeld & Nicolson, London.
Competing interests: No competing interests
I retired from active practice 14 years ago but I still have had the
opportunty to observe many infants being breast fed only("current"
fashion) in the US) until 6 months of age.On the average they appear to be
at least 3 months below the standards of my own care years.( 1956 - 1996)
which included-cereals at 6wks, strained fruits at 2 months,and strained
vegetables at 4-5 mos.Food allergies were essentially nonexistent
Competing interests: No competing interests
On behalf of the Scientific Advisory Committee on Nutrition (SACN),
we are responding to the article published in the BMJ last week by
Fewtrell et al questioning the scientific basis for current UK infant
feeding advice . The authors selectively reviewed evidence on the
appropriate age at which to introduce complementary food into the diet of
breastfed infants, and we wish to comment on several statements they have
made about the role of SACN in scrutinising relevant evidence. SACN is a
committee of independent experts appointed under Nolan Principles for
public appointments to advise UK Governments. In its deliberations, the
Committee takes account of a range of views and, where appropriate,
augments its membership by drawing in further expertise. It works in
collaboration with other organisations including the Royal College of
Paediatrics and Child Health (for example work on the application of World
Health Organization growth standards in the UK).
Firstly, with regard to the UK's response to the World Health
Organization's revised recommendations on breastfeeding in 2001, it is
incorrect to say that "..the Department of Health's Scientific Advisory
Committee on Nutrition (SACN) was not asked to formally consider the
scientific evidence". The issue was initially considered in 2000 by an ad
hoc group of experts invited by the Department of Health, as SACN was not
then fully constituted. The meeting was chaired by Professor Alan Jackson
as the inaugural chair of SACN. The Group concluded "That there is
sufficient scientific evidence that exclusive breastfeeding for 6 months
is nutritionally adequate". It acknowledged a need for flexibility in that
mothers may introduce complementary foods earlier than this for personal,
social and economic reasons, but stated these should not be given before
the end of 4 months, or 17 weeks.
In 2001, SACN formally re-examined the evidence and stated: "...
there is sufficient scientific evidence that exclusive breastfeeding for 6
months is nutritionally adequate". The Committee also acknowledged the
need for flexibility in that mothers may introduce complementary foods
earlier than this for personal, social and economic reasons but it stated
these should not be given before the end of 4 completed months, or 17
weeks. All minutes and agenda papers relating to the matter are in the
public domain at http://www.sacn.gov.uk/pdfs/sacn_01_02min.pdf.
SACN has subsequently examined in depth several topics relevant to
the content of the Fewtrell et al review and provided its advice to
Government. The relevant reports and commentaries have all been published
and most have been subjected to open public consultation. Thus "broad
professional consultation" has always been a part of the SACN process and
particularly a feature of all its major reports. Specifically Fewtrell et
al did not acknowledge the following reviews:
* In 2007, SACN recommended adoption by the United Kingdom of the
World Health Organization's international growth standard (WHO Growth
Standards for children up to 5 years 2006). This describes the growth
of infants who were exclusively or predominantly breastfed receiving
complementary foods at an average age of 5.4 months3. The pattern of
growth described by these standards is internationally acknowledged as
compatible with both short- and longer-term infant health.
* SACN has reviewed the adequacy of both iron and energy supply
during exclusive breastfeeding in forthcoming reports, both of which were
open for public consultation in 2010
These reports set out the evidence in its entirety and do not support the
conclusions drawn by Fewtrell et al.
* Together with the Committee on Toxicity (COT), SACN has recently
reviewed the evidence relating the risk of coeliac disease and type 1
diabetes mellitus to the age at which gluten is introduced into the
infant's diet. The Committees have jointly formed the opinion that
currently available evidence on this topic is insufficient to support
recommendations about the appropriate timing of introduction of gluten
into the infant diet for either the general population or high-risk sub-
populations. Specifically the Committees do not support the suggestion of
Fewtrell et al that gluten should be introduced between 3 and 6 months.
The draft opinion of both Committees is in the public domain at
In suggesting that changes to infant feeding policy should be subject
to audit, the authors failed to acknowledge that historically infant
feeding policy has been evaluated more closely in the United Kingdom than
in most other countries. The quinquennial surveys of infant feeding
practice have documented trends since 1975 and a detailed national survey
of the diet and nutritional status of infants and young children (4-18-
months of age), funded by DH and the Food Standards Agency, is currently
in progress. The Scientific Advisory Committee on Nutrition carefully
considered the findings of the Infant Feeding Survey 2005 and published a
commentary in 2008 . In 2005, following the changes to infant feeding
policy made in 2003, the proportion of mothers in the UK introducing
solids before 4-months of age fell to 51% from 85% in 2000 . Similarly
the proportion introducing solids before 3-months of age fell to 10% from
24%. SACN considers these to be encouraging changes that are likely to
benefit infant health and does not share the concerns raised by the
It is important to acknowledge the challenges that exist in
interpreting the evidence that relates patterns of infant feeding to
health, but these are not unique to infant feeding and are common to many
other areas of public health nutrition. SACN has specifically considered
these and in the interest of broadening public understanding published its
approach to the interpretation of evidence
(http://www.sacn.gov.uk/pdfs/sacn_framework_03_03_09.pdf). It combines
evidence from a range of sources in order to provide balanced advice to
Government taking account of both benefits and risks. Fewtrell et al thus
suggest nothing new in asking for "A synthesis balancing the risks and
benefits of the proposed intervention, accounting for a range of possible
SACN's current advice to Government on the nutritional adequacy of
exclusive breastfeeding for 6 months remains unchanged and the Committee
continues to review all new evidence as it emerges. Furthermore, it is
about to embark on a review of all aspects of the scientific evidence
underpinning infant and young child feeding policy in the UK. The SACN
Subgroup on Maternal and Child Nutrition started scoping this work in
September 2010 and the first meeting will take place later this year.
Dr Anthony F Williams, Chair of the SACN Subgroup on
Maternal and Child Nutrition
Dr Ann Prentice, Chair of the Scientific Advisory
Committee on Nutrition (SACN)
1. Fewtrell M, Wilson DC, Booth I, Lucas A (2011) Six months of
exclusive breast feeding: how good is the evidence? BMJ 342:c5955. doi:
2. Scientific Advisory Committee on Nutrition (2007) Application of
WHO growth standards in the UK. London: The Stationery Office
3. WHO Multicentre Growth Reference Study Group (2006) Complementary
feeding in the WHO Multicentre Growth Reference Study. Acta P?diatrica
Suppl 450: 27 - 37
4. Bolling K, Grant C, Hamlyn B, Thornton A (2007) Infant Feeding
Survey 2005. London: The Information Centre
5. Scientific Advisory Committee on Nutrition (2008) Infant feeding
survey 2005: A commentary on infant feeding practices in the UK. London:
The Stationery Office
Competing interests: No competing interests
I agree completely with what is said in this post. One thing that
puzzles me is that Lucas's infant feeding text states that the evidence
about iron and cognitive development is "incomplete". And Lucas expressed
concern only about BF babies over 6 months who are getting solids of low
iron bioavailability, plus possibly SGA babies under 6 months (whose
postnatal growth is usually monitored). He expressed no concern about
exclusively breastfed babies under 6 months, as all research to date shows
little evidence of any deficits, due to the transport factors that assure
80% bioavailability of breastmilk iron (reduced by added solids). So what
causes (Fewtrell and) Lucas to raise this iron issue at all in a paper
discussing lowering the age for solids from 6 to 4 months? And what solids
would be safe?
Iron was a major 1980s competitive formula marketing theme, and it
seems to me that some of the mythology created then still lingers, and
will for as long as references are not critically checked. I suppose this
is not surprising given the massive worldwide resources used in the
industry campaigns. Ironically, every month not fully breastfeeding will
increase a mother's risk of anaemia as her menses will return!
Competing interests: No competing interests
As a doctor on maternity leave, exclusively breastfeeding my 5 1/2
month old daughter, I rely on BBC radio to keep me up to date with the
news. Whilst listening to coverage of Fewtrell's article on Radio 4's
Today Programme on 14th January, I lost count of the number of times the
word "research" was used by reporters. "Their research which contradicts
government advice..." "...there has been further research..." "...their
research which is published in the BMJ..." "...led the research...". On
hearing that the authors "have been reviewing recent studies..." I was
looking forward to reading their systematic review on BMJ online. Dr
Fewtrell confirmed live on BBC Radio 2 Jeremy Vine's show that "this is
actually not a new piece of research; this is a review that myself and my
colleagues have done of existing research." I was therefore shocked to
find that this is not a systematic review but rather an opinion paper. If
the media cannot be trusted to accurately report such matters, then more
careful consideration should be given by the scientific community before
publishing a paper which may have widespread public health implications.
Competing interests: I am still exclusively breastfeeding my 5 1/2 month old baby
Fewtrell et al raise the concern that 6 months of exclusive breastfeeding increases the risk of iron deficiency anaemia in comparison with weaning at 4 months . I believe they have overstated the strength of the evidence for that concern.
The main evidence presented in support of an increased risk of anaemia came from the study by Chantry et al . The findings of that study were, however, inconsistent. Findings of an increased risk of self-reported anaemia, which may have been subject to bias, were not matched by laboratory-confirmed low haemoglobin values. I have written about this in more detail elsewhere.
We are also not told what literature search methods Fewtrell et al used, so we do not know whether other relevant evidence may have been published.
Fewtrell et al also state that anaemia following 6 months of exclusive breastfeeding "is of concern given irreversible long term adverse effects on motor, mental, and social development after iron deficiency". Those irreversible long term adverse events have not been shown as a consequence of 6 months of exclusive breastfeeding. They were a consequence of anaemia from other causes. If prolonged exclusive breastfeeding does cause anaemia, then it is not safe to conclude that the consequences would be the same as for anaemia of other causes. Infants with anaemia due to late weaning may differ in important ways from infants with anaemia due to other causes.
The idea that 6 months of prolonged breastfeeding could cause harm via iron deficiency anaemia appears to be based more on speculation than on evidence.
1. Fewtrell M et al. Six months of exclusive breast feeding: how good is the evidence? BMJ 2011; 342:c5955
2. Chantry CJ, Howard CR, Auinger P. Full breastfeeding duration and risk for iron deficiency in U.S. infants. Breastfeed Med 2007;2:63-73
Competing interests: No competing interests
The 'Comment' paper by Fewtrell et al in which questions are raised
about policy recommendations on the duration of exclusive breastfeeding
has, not surprisingly, hit the national and international headlines.
Negative comment on breastfeeding in professional and scientific journals
usually does, and widespread interest was predictable. This coverage has
resulted in confusion among families and health professionals, not just
about the health outcomes related to the duration of exclusive
breastfeeding, but about the nutritional adequacy of breastfeeding at all
after four months of age. In the past decade or so there have been
considerable advances in developing evidence-based policy on breastfeeding
across countries and across successive governments. The evidence base for
such policy has derived from thoughtful, careful scientific advances (1,2)
high quality systematic reviews on health outcomes (3,4) and good quality
evidence and reviews on effective strategies to enable women to breastfeed
(5,6,7). Such positive developments have been effected by collaborations
between researchers, policy makers, and the health professionals and
voluntary sector organisations who understand just how hard it is for
women to breastfeed in a culture that is antagonistic to breastfeeding
(8,9,10). In speculating about the nutritional adequacy and even safety of
delaying the introduction of solid foods to breastfed infants until about
six months, this paper has put this large-scale collaborative work at risk
and undermined confidence in breastfeeding.
It is important therefore to consider whether this paper offers a
worthwhile contribution to knowledge to compensate for this risk.
Although published as a Comment, the front page of the BMJ website
indicates that this paper 'reviews the evidence'. Judged as a review,
this piece fails on all quality criteria (11). No methodological details
such as a search strategy or inclusion/exclusion criteria are described to
demonstrate that bias was avoided in the selection of studies. There is no
critique of included studies, which would have identified that some of
those referred to are very small or only examine specific at-risk groups,
or do not relate to infant feeding at all (12,13); and it would have
distinguished between research studies, reviews, and opinion and
speculative articles. In other words, the principles of systematic
reviewing, developed to protect professionals and the public from
incomplete and biased information, have been disregarded. Two examples
illustrate the problems that result. Fewtrell et al challenge the findings
of the 2002 WHO review of optimal duration of exclusive breastfeeding
(14); these authors updated their Cochrane Review of this topic in 2006
(15). In support of their challenge they cite a review on the age of
introduction of complementary foods to the healthy full-term infant (16),
indicating that it included 33 studies and 'found no compelling evidence
to support change' from four months to around six months of exclusive
breastfeeding. A quick appraisal of this Nestle-supported review shows
that the 33 included papers derived from 25 studies; that studies included
both formula and breastfed babies; that those studies whose authors
concluded that delayed introduction of complementary foods to around six
months was appropriate were of relatively higher quality than those that
supported earlier weaning; and that the authors of this review in fact
state that 'there is no clear evidence to either support or refute a
change to the current recommendations'. The second example is of
particular concern. Fewtrell et al list possible consequences of iron
deficiency in their Box 2; the list includes catastrophic outcomes that
any parent would try to avoid including 'irreversible adverse mental,
motor, and psychosocial outcomes'; yet the evidence cited by these authors
in support of breastfed infants being deficient in iron comes from a US
study where the number of babies exclusively breastfed is very small, and
in which such serious iron deficiency was not measured (17). Fewtrell et
al omit to mention the well-evidenced, though often forgotten, increased
bioavailablity of iron in breastmilk (18). They also do not mention the
findings of a large RCT that demonstrated a significant decrease in IQ and
other measures of cognitive function related to formula feeding (19). A
reappraisal of the evidence may be timely, as Fewtrell et al suggest, but
their paper does not achieve this aim.
Researchers have limited time in which to write papers that will not
enhance their Research Excellence Framework profile (though such papers
will increase their citation count). Why choose to examine a topic that
is not a public health priority in a country where fewer than 1% of babies
are breastfeed exclusively at six months (20)? In regard to the timing of
the introduction of solid foods, the more pressing public health question
relates to the duration of exclusive formula feeding, which affects very
large numbers of babies in the UK and globally, yet lacks an evidence base
and has not been subjected to systematic review. WHO recommendations
refer only to breastfeeding (21), and the more recent EFSA scientific
opinion (22) also only examined evidence related to breastfeeding.
Studies and reviews of the adequacy and safety of exclusive formula
feeding should include assessment of the nutritional adequacy of a class
of products that is accepted as being of lower quality than breastfeeding,
infection and contamination risks in use of these products compared with
breastfeeding, and the risk of allergy and intolerance resulting from use
of products that include a range of non-human ingredients. Assessment of
the impact of not breastfeeding, exclusively or at all, on women's health
and wellbeing is also important (23) an aspect not addressed by Fewtrell
Sadly, this paper has not advanced knowledge, but rather confused and
misled. It has thereby resulted in national and international media
coverage that is likely to increase the sales of formula. Peer review by
those with knowledge of the field should have prevented that.
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11. Centre for Reviews and Dissemination CRD's guidance for undertaking
reviews in healthcare. 2009. CRD, University of York.
12. Lozoff B, Jimenez E, Hagen J, Mollen E, Wolf AW. Poorer behavioural
and developmental outcome more than 10 years after treatment for iron
deficiency in infancy. Pediatrics 2000;105:E51.
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deficiency and cognitive achievement among school-aged children and
adolescents in the United States. Pediatrics 2001;107:1381-6.
14. Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding:
a systematic review. World Health Organization, 2002.
15. 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. Last assessed as up to date Dec 30, 2006.
16. Lanigan JA, Bishop J, Kimber AC, Morgan J. Systematic review
concerning the age of introduction of complementary foods to the healthy
full-term infant. Eur J Clin Nutr 2001;55:309-20
17. Chantry CJ, Howard CR, Auinger P. Full breastfeeding duration and risk
for iron deficiency in U.S. infants. Breastfeed Med 2007;2:63-73.
18. Saarinen UM, Siimes MA, Dallman PR. Iron absorption in infants: high
bioavailability of breast milk iron as indicated by the extrinsic tag
method of iron absorption and by the concentration of serum ferritin. J
19. Kramer MS, Aboud F, Mironova E, Vanilovich I, Platt RW, Matush L, et
al. Breastfeeding and child cognitive development: new evidence from a
large randomized trial. Archives of General Psychiatry. 2008;65(5):578.
20. Bolling, K., Grant, C. & Hamlyn, B. Infant Feeding Survey 2005.
2007; The Information Centre for Health and Social Care: London.
21. World Health Organization. 55th World Health Assembly. Infant and
Young Child Nutrition. World Health Organization, 2002 (WHA55.25).
22. European Food Safety Authority (EFSA), EFSA Panel on Dietetic
Products, Nutrition and Allergies (NDA). Scientific opinion on the
appropriate age for introduction of complementary feeding of infants. EFSA
23. Collaborative Group ibid
Competing interests: No competing interests