Scientific Advisory Committee on Nutrition replies to Mary Fewtrell and colleagues

Fewtrell and colleagues selectively reviewed evidence on the appropriate age at which to introduce complementary food into the diet of breastfed infants.1 We comment on several of their statements about the role of the Scientific Advisory Committee on Nutrition (SACN) in advising UK governments on this issue. SACN is a committee of independent experts appointed under Nolan principles to advise these governments.

It is incorrect that SACN “was not asked to formally consider the scientific evidence” supporting the World Health Organization’s revised recommendations on breast feeding in 2001. The issue was initially considered in 2000 at a meeting chaired by the inaugural chair of SACN. It concluded: “There is sufficient scientific evidence that exclusive breast feeding for six months is nutritionally adequate.” SACN endorsed this view in 2001, acknowledging the need for flexibility since mothers may introduce complementary foods earlier than this for personal, social, and economic reasons. It nevertheless stated these should not be given before the end of four completed months.2

SACN has subsequently published reports and commentaries on several topics relevant to Fewtrell and colleagues’ review. All have been published and most were open to public consultation. Thus “broad professional consultation” has always been part of the SACN process. Fewtrell and colleagues did not acknowledge three reviews:

• •In 2007 SACN recommended adoption of the 2006 WHO international growth standard for children up to 5 years old.3 This describes the growth of exclusively or predominantly breastfed infants receiving complementary foods at an average age of 5.4 months4; this pattern of growth is internationally acknowledged as compatible with both short term and longer term infant health. This work was conducted collaboratively with experts nominated by the Royal College of Paediatrics and Child Health

• •SACN will endorse the adequacy of iron and energy supply during exclusive breast feeding in forthcoming reports that were open for public consultation in 2010.5 These examine the issues in depth and do not support the views of Fewtrell and colleagues

• •SACN and the Committee on Toxicity (COT) have reviewed evidence relating the risk of coeliac disease and type 1 diabetes to the age at which gluten is introduced into an infant’s diet.6 The committees do not consider evidence sufficient to support introduction of gluten between 4 and 6 months of age.

Fewtrell and colleagues suggest that changes to infant feeding policy should be subject to audit but fail to acknowledge that infant feeding policy has long been evaluated closely in the UK. Quinquennial surveys of infant feeding have documented trends since 1975, and a government funded national survey of the diet and nutritional status of infants and young children is in progress. Following changes to policy in 2003, the proportion of mothers in the UK introducing solids before 4 months of age fell to 51% from 85% in 2000.7 The proportion introducing solids before 3 months more than halved. SACN believes that these changes will benefit infant health8 and does not share the concerns of Fewtrell and colleagues.

Interpreting evidence relating infant feeding to health poses many challenges, but these are common to many areas of public health nutrition. SACN combines evidence from a range of sources to provide balanced advice to government.9 Fewtrell and colleagues thus suggest nothing new in asking for “a synthesis balancing the risks and benefits of the proposed intervention, accounting for a range of possible outcomes.”

SACN’s advice to government on the nutritional adequacy of exclusive breast feeding for six months remains unchanged. The committee continues to review all new evidence and in September 2010 started investigating the scope of a detailed review of the scientific evidence underpinning infant and young child feeding policy.