Intended for healthcare professionals


Six months of exclusive breast feeding: how good is the evidence?

BMJ 2011; 342 doi: (Published 13 January 2011) Cite this as: BMJ 2011;342:c5955

Breastfeeding is more than infant nutrition

January 14, 2010

Dear Editors:

With thanks to my friends and respected colleagues for addressing the
importance of six months of exclusive breastfeeding, it would seems that
their argument considers breastfeeding primarily as a replacement for
formula feeding. The health benefits for the mother, both short and long
term, are not explored, and the risks and expense of formula feeding, even
in industrialized settings, are brushed aside.

For the most part, this article actually presents substantial
additional data supporting six months for the infant and child health
outcomes while noting the few findings that might speak against it. One
possibly new issue raised, based on a single Swedish study, is coeliac
disease; the article itself notes that gluten load, rather than timing,
might well be the culprit. Concerning iron stores, we know that much of
this problem could be addressed with proper delay of cord clamping, giving
infants greater iron stores from birth, or if still needed, later
micronutrient supplementation might be considered. This birth-related
issue and other maternal issues are disregarded: six months (vs. four)
exclusive breastfeeding has many advantages for maternal health and birth
spacing in less developed and industrialized countries alike. Also, the
large body of published research on later maternal and child obesity,
cancer and related diseases is barely considered. In sum, there is little
here to argue against the definition of optimal feeding practice, for
mother and child, to remain exclusive breastfeeding for six months.

As to the research from developed countries, such research on
exclusive breastfeeding in developed countries is very difficult to
interpret in part due to small self-selected numbers and in part due to
inadequate definitions of breastfeeding practices. The WHO nutrition
section and other nutrition groups tend to define the term exclusive
breastfeeding only in its role as a food, and therefore the definition of
exclusive breastfeeding generally includes the feeding of expressed milk
and/or pasteurized donor milk. Such milk feeding may not be creating the
same physiological, hormonal and gut floral/fauna responses in the mother
and child as is created by direct breastfeeding, and, in situations where
there may be considerable separation of mother and child, the immune
composition of the milk may no not address the child's environmental
exposures. We are far from understanding the differences in health
outcomes for mother and child with the use of pumps and expressed milk, a
very common practice in the US. Other concerns, such as delayed exposure
to food flavors, would not appear significant, given recent research that
has confirmed that breastfed infants are already exposed to the flavors of
foods ingested by mother through her milk.

On a different issue, it may also be important to correctly the
statement on US government support. USG policy has noted the importance of
six months, rather than 4-6, since the preparation of the US DHHS
Blueprint for Action on Breastfeeding, published in 2000, and has been
supporting six months exclusive breastfeeding for more than 5 years with
the Healthy People goal for the Nation to increase exclusive breastfeeding
through six months.

Finally, it might be noted that three of the four authors declare
receiving funding from the infant food industry, which would benefit from
policy that dictated a significant increase in the need for infant

Rather than calling for truncation of exclusive breastfeeding,
limiting its myriad of positive immediate health, child spacing and long-
term health effects, let us instead call for 1) delayed cord clamping for
iron stores, with iron supplements as needed in later infancy, 2) research
on the impact of exclusive breastfeeding vs. expressed milk feeding on the
health of both mothers and their children, and, most of all, 3) unbiased,
informed, and mother-centered support - clinical, social and economic - so
that women may make an unbiased, informed infant feeding choice, and
succeed in six months of exclusive breastfeeding.


Miriam H. Labbok, MD, MPH, FACPM, IBCLC, FABM

The Carolina Breastfeeding Institute (CGBI) Professor, and Director, CGBI
Department of Maternal and Child Health
Gillings School of Global Public Health

The University of North Carolina at Chapel Hill
Chapel Hill, NC 27599-7445


--Labbok is on the Board of the Academy of Breastfeeding Medicine and
North America Representative on the Board of Directors, World Alliance for
Breastfeeding Action

--CGBI is a member of The North Carolina Breastfeeding Coalition; The
United States Breastfeeding Committee; The Partnership for Maternal,
Newborn and Child Health.

--CGBI is a component of The WHO Collaborating Centre for Research
Evidence for Sexual and Reproductive Health at UNC

Competing interests: No competing interests

14 January 2011
Miriam H. Labbok
Carolina Global Breastfeeding Institute, Dept of Maternal and Child Health, University of North Caro