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How long should a baby be exclusively breastfed?

This question was posted the Infant and young child feeding interventions forum area and has 21 replies.

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Melanie Bruns

Program coordinator / German Agro Action

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22 May 2012, 19:51

A recently published study found out that exclusive breastfeeding for 6 months enhances chances of developing allergies, as well as iron deficiancies and therefore 4 months was recommended. I was told that the study had a mistake in the a design and that the result is therefore biased/ not right. And for those who have read it, do you also think the study design was faulty? Personally (I am a Nutritionist) I did not manage to exclusively breastfeed for six months (nor do I know of anyone who did), as my baby was almost grabbing the food out of my hand when I was eating. She has been healthy, had no GIT problems. So when I am asked for advice I am now really struggeling to give a straight answer.

Bijoy SARKER

Action Contre La Faim | Action Against Hunger

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23 May 2012, 12:02

Can you please post the link of the site where that study can be found :o

Chantal Autotte Bouchard

AAH

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24 May 2012, 01:55

Hi, As my colleague in ACF Bangladesh i'M also interested about the weblink or the reference of the study. Thank you

Karleen Gribble

Assoc Prof Western Sydney University

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24 May 2012, 02:14

Hi, There is quite a lot of research looking for an explanation for the marked increases in allergy in developed country contexts in recent decades and for factors that might decrease the risk of allergy. One area of investigation has been into the impact of infant feeding practices on allergy. Unfortunately, most of those carrying out the research are solely allergy specialists and do not understand infant feeding very well. This has resulted in the vast majority of such research not having good definitions of what constitutes exclusive breastfeeding and it is highly likely that in most of these studies there were no or very few "exclusively breastfed" infants in the study. Virtually all studies are also retrospective which brings into question recall bias. However, these problems have not stopped the baby food industry from lobbying for a change in recommendation for the duration of exclusive breastfeeding and industry funding in Australia and Europe via the professional association of allergists who have been providing education to health professionals stating that the duration should be changed. We really don't know the impact of early introduction of other foods vs exclusive breastfeeding is on allergy- we just don't have enough research with tight and reliable definitions. There should be no confusion as to what recommendation to use with parents. The recommendation remains for exclusive breastfeeding for 6 months. Individual mothers will make their own decisions based on their personal circumstances but no health professional should provide advise based on their own experience vs public health recommendations.

Chantal Autotte Bouchard

AAH

Normal user

24 May 2012, 03:27

Hello, If we exclude the link to the allergy. Here we have two debates and the second interest me. Actually experiences shouldn't affect staff in the recommendation of course. But what about the rate of exclusive breastfeeding up to 6 months (in the world in general) is what mothers do happen in France, Guine, or Canada to breastfeed optimally to 6 months. I'm curious to know what "global" rate is. Because in fact, also in countries with humanitarian cause or not, I think this also raises the problem and it is this that should also include studies that recommendation between reality and sometimes there is a chasm. thank you C.

Karleen Gribble

Assoc Prof Western Sydney University

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24 May 2012, 05:12

Chantal, You are right there is a huge gap between recommendation and practice in most contexts. In Australia, very few babies are exclusively breastfed to 5 months (15% according to the latest survey)- for most of these babies exclusivity was terminated by the infant being fed infant formula. However, the recommendation to breastfeed to 6 months still has an impact. When the Australian government was considering whether to change the recommended duration from 4 to 6 months (now many years ago!) this was one thing that they looked at. What they found is that when parents were told to wait until 4 months before the introduction of complementary foods many did not do so, many introduced complementary foods at 2 or 3 months however, when they were told not to introduce complementary foods until 6 months although few managed this many waited until 4 or 5 months to introduce complementary foods and very few did so at 2 or 3 months. So parents might not get to the stated recommendation but it will affect what they do regardless.

Ted Greiner

retired Professor of Nutrition

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24 May 2012, 07:40

You can see recent data on breastfeeding indicators from industrialized countries (though not exclusive breastfeeding for 6 months, but rather for 3 or 4 months) on page 43 of the excellent Save the Children report Nutrition in the First 1000 Days: http://www.savethechildren.org/atf/cf/%7B9def2ebe-10ae-432c-9bd0-df91d2eba74a%7D/STATEOFTHEWORLDSMOTHERSREPORT2012.PDF Although Australia ranks high on most other indicators related to mother and child welfare, on exclusive breastfeeding it doesn't rank much above the middle among the 36 countries in this chart. I would strongly argue that how many women currently practice six months of exclusive breastfeeding has no relevance to its importance for maternal and child health and should have no importance to our commitment to achieving it. First, exclusive breastfeeding was not even recommended before about 1990 and is "traditional" in the sense of being the norm during say the past century virtually nowhere. So it will take time. Second, one does not have to go far back in history to find that no one implemented measures we now take for granted (women's right to vote, use of seat belts in cars, insecticide-treated bednets in malarial areas). Should we in the past have reduced our commitment to them because they were rarely achieved? Why should exclusive breastfeeding be any different? Note that, just as was true in the early stages for those 3 measures, exclusive breastfeeding cannot be achieved by simply "educating", let alone putting pressure on seemingly responsible individuals. Young mothers lack the power to implement it in most cultures. Educational messages should rather be directed mainly to older women and especially fathers--who do have the power if they possess the knowledge. And supportive social structures are needed. The Save the Children table refers also to these: paid maternity leave, Baby Friendly Hospitals, and government support for the International Code of Marketing of Breast-Milk Substitutes. If those are lacking, should the exclusive breastfeeding goal be abandoned? Or maybe shortened to make our statistics look better? Or should we direct our advocacy (and criticism) where it belongs--to governments that are failing to do their duty in support of the rights of mothers and babies? (Note that the USA, which does not even recognize that mothers and babies have economic, social or cultural rights, also is ranked the lowest.)

Florence

Normal user

24 May 2012, 08:07

Thanks Ted. I am in agreement with your point of view. As nutritionists and health workers, its our responsibility to advocate, promote and protect exclusive breastfeeding. We should not let our personal views affect our duties. If we fail to exclusively breastfeed ourselves, we need to identify circumstances sorrounding the situation and seek assistance. In my practices, many mothers have successfully exclusively breastfed their infants upto 6 months .Sometimes i meet mothers who have not introduced compelemetary feeds at 7 months and their babies are still healthy and counsel them to introduce complemetary foods. Thus, exclusive breastfeeding is possible, and is a vital strategy for prevention of malnutrition among infants < 6 months in developing countries.

Marie McGrath

Mrs

Forum moderator

24 May 2012, 08:33

Dear All I consulted with WHO regarding this question and they shared the following: The BMJ article “Six months of exclusive breastfeeding: how good is the evidence”, that was published in Jan 2011. The abstract is at the following link (I am trying to locate the full paper to share with you): http://www.bmj.com/content/342/bmj.c5955 See also the article in BBC: http://www.bbc.co.uk/news/health-12190006 Following that, see WHO’s statement: http://www.who.int/mediacentre/news/statements/2011/breastfeeding_20110115/en/#.T7ukpHtMSrU.email A letter and comment was subsequently published in the BMJ: http://www.ennonline.net/resources/905 I think the original question posed demonstrates the reality of applying what are population based recommendations to individuals. There will always be a range of safe practice at an individual level that will involve exclusive breastfeeding to less than (or longer than) six months. What is right for that infant and mother will depend on the individual circumstances. But in appreciating this, it is essential not to bias objective assessment and advice on our own personal experiences. As Karleen reflects, if you move the 'goal posts', the range of EBF duration risks shifting downwards. Support to a mother and baby will require identifying and helping address those barriers to exclusive breastfeeding (whether social, economic, informed practice, etc) that are hampering a mother to continue, and that are not in the best health, nutrition and developmental interests of her baby in their circumstances. I hope this exchange on en-net has helped address your original questions, but please continue this discussion if it remains unresolved for you. This is a valuable issue you have raised, that I am sure many have been toying with.

Melanie Bruns

Program coordinator / German Agro Action

Normal user

24 May 2012, 08:39

Thank you All for your very valuable comments! Before I was a mother myself, I was a 'die-hard' advocate for exclusive breastfeeding for 6 months. It is not that I failed to exclusively breastfeed. I studied my child and her behaviours and learned to understand when she was ready to try other foods. I was very hesitating, being a nutritionist, but after discussion with other nutritionists and literature review I tried with a spelled porridge. I am lucky to have the confidence and knowledge to make such decisions. But what about all the other mums out there? Yes, it is important that we stick to a 'safe' recommendation. But should we not also advocate more on hygiene and how to introduce complementary foods? I am comparing the recommendation with the following: Abstinence versus condoms. Some organisations cannot advocate for the use of condoms and therefore advocate for abstinence. But how many people out there take the recommendation seriously?

Chantal Autotte Bouchard

AAH

Normal user

24 May 2012, 13:54

Hello Karleen, Thank you for your response, which joined my thoughts. Have a line of conduct, promote, hoping to reach the best. The problems encountered in exclusive breastfeeding are many and we are actually confronted with multiple belief in industrialized countries as in developing countries. Always a grandmother to say, I gave you ate was 3 months and you're in great shape or that child hunger has eaten give him your milk is not enough. We now know a priori that the milk meets the needs up to 6 months, at least in general, all scenarios are possible, as multiple and various as the number of child who is born in every second. Someone once said: "Terrorists of exclusive breastfeeding" it made me smile, because in some countries we have effectively no chance of some countries indistruialisé to have support in this approach is beneficial for many mothers, despite all efforts being made. This leads me to guilt, we have the support (Baby Friendly Hospital, Group Mom Nursing, Ball League etc.) or not I think we should lean on the mothers face has felt this, breastfeeding is not an easy task that we are totally dedicated to our children or not (maternity leave therefore to devote himself entirely to him) and this leads to many mothers in Africa as in France or England helplessness and impression of being a bad mother who leaves the very fact causes a problem in the mother / child relationship seen in the amount of milk produced can be decreased by discomfort or complete cessation of breastfeeding. Beware any such questioning does not jeopardize the health importance of exclusive breastfeeding child I ask substantive questions on a constant reality that is found on the ground no matter our location. Because even if it goes through three steps to educate, change behavior and achieve good practice, it remains clear that it is not obvious to exclusively breastfeed even if all conditions are met because we n 'have any control of the human feeling. This does not imply a change of recommendation for me but an understanding of the situation in which mothers can come together. I have no answer on how we can work it and I do not really expect an answer, but more a reflection.

Colleen Emary

Technical Advisor, Nutrition

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24 May 2012, 16:21

Very interesting discussion. On a related note, I'm wondering what advocacy efforts are currently underway to have the International Labour Organization convention on Maternity Protection - C183, updated to 6 months, rather than the current provision of 14 weeks? While not all countries have ratified this convention, there are many that do and have based their maternity leaves on 14 weeks, which of course is not sufficient to support EBF.

Ted Greiner

retired Professor of Nutrition

Normal user

25 May 2012, 00:24

I visited the ILO in 1990 to find out how to convince them to improve on the maternity protection conventions that existed at the time. Their orientation was to REDUCE maternity protection, and three different parts of the organization all agreed on this for different reasons, as follows: 1. Giving benefits for having babies is pro-natalist (encourages people to have more babies), the opposite of what most low-income countries need. 2. Giving extra benefits to women is not gender neutral and indeed, discourages employers from hiring them. (Many countries now offer parental leave instead. Sweden requires the father to take at least 2 months of it.) 3. Paying some workers not to work increases the cost of labor and reduces labor productivity, the opposite of what many countries are trying to do to attract greater foreign investment. Of course it's possible to argue against those points; there's a bit of data one can use in doing so. But there's some undeniable truth to some of them which means we get back to "what's the purpose of development?" and the human rights arguments (which make economic arguments irrelevant). Then in 2000 ILO did hold a convention to revise the maternity protection convention, hoping to weaken it. The main reason for wanting to do so was to get more countries to sign on to at least something. They quite correctly (it turns out) argued that a convention offering more benefits would result in very few countries ratifying it. The World Alliance for Breastfeeding Action sent lobbyists (something ILO was not used to and had difficulty stopping). It was rather easy for them to convince many delegations who did understand (or perhaps did not agree with) all of ILO's concerns to vote for MORE not less benefits. So the 2000 Convention is in fact stronger on several points than the earlier ones from the 50s and I think about 1918. So even though the current convention may look weak to us in the "breastfeeding community", further strengthening it will take quite an effort at this point!

Sam Oluka

Nutritionist / Food Scientist

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25 May 2012, 08:22

Very informative sharing. During one of my volunteer visist to a health facilty, I found my self chatting with mothers about breast feeding... One mother told me of how she never allows her children to eat anything before 1-1.5 yrs..Reason...She did not want them soiling cloths let alone grow up with a high appetite for nice things... She added all her children were healthy! Challenge is I did not have the chance to see any of the children. I requested her to come over with them (all below 5 yr-3 children) next thursday 31st. May be I shall learn something during the session. Most are from a rural setting. Will hopefully share with you again.

Adan Yusuf Mahdi

CTC Admin officer OXFAM NOVIB/SAACID SOMALIA

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26 May 2012, 10:58

Thanks for the long discussion about this issue of exclusive breast feeding I my self as ctc nutrition worker at Mogadishu ,my youngest child Is 4months old Feeds her mothers, Bresast and I will continue up to six months of age then I will start complimentary food after six months and the overall programme of iycf at our ctc sites is improving and most of our beneficiaries are applying the exclusive breast feeding for the first six months of life and we have seen the feed back of the that excercise and no one one was complaining that allergy.therefore I am worried the new emerging concept which is ellergic reaction to the child who continue breast feeding for the firs six months of the life exclusively so should I continue or stop it ? Thanks

Karleen Gribble

Assoc Prof Western Sydney University

Normal user

27 May 2012, 03:02

Dear Adan Definitely do not make any suggestion of change in practice away from 6 months exclusive breastfeeding. Since there have been no studies for which there is any confidence that there was an exclusively breastfed control group which showed an increased risk of allergy it cannot be said that exclusive breastfeeding increases the risk of allergy. Furthermore, the risk of allergy is one that is mainly of concern in developed country contexts where rates of allergy have increased greatly in recent decades, there has not been a similar increase reported in developing country contexts. I think that the concern in your work environment would be that early complementary feeding would result in increased risk of diarrhoea and respiratory infection. There is very good evidence that early complementary feeding results in increased infection. Continuing to recommend and support exclusive breastfeeding for 6 months is important.

Tamsin Walters

en-net moderator

Forum moderator

4 Jun 2012, 12:30

From Felicity Savage: Dear all, Those of you who are worried about the hints that babies suffer less allergies if they are given complementary foods early should look at the article by Fewtrell, British Medical Journal, 22 January 2011. This gives a review of the evidence, and refers in particular to articles by Du Toit, Prescott, Olson and Norris which provide the main evidence for the claim, about the risk of celiac disease in wheat eating populations (not an issue in rice eating populations) and peanut allergy. The evidence of such an effect is very limited, they are studies before 2008, and the information about breastfeeding is unclear. In the peanut study, very few infants were given them until after 6 months. Until there is new and stronger evidence we should continue to promote 6 months exclusive breastfeeding. Ted Greiner in his thoughtful contribution mentions some of the interventions needed to increase exclusive breastfeeding, (the Code, BFHI, Maternity protection). But the intervention for which there is most evidence of an effect is support from peer counsellors – or at least continuing support postnatally from a lay or health worker trained in breastfeeding counselling, with both communication and clinical skills. Mothers need at least 7 contacts with a skilled person, from pregnancy and through the early months of life. The more contacts they have, the more likely they are to breastfeed exclusively. Until this is recognised as a public health imperative, exclusive breastfeeding rates are unlikely to increase. The BFHI and other measures by themselves are unlikely to effect change. Felicity

Anonymous 1570

Nutritionist

Normal user

3 Sep 2012, 19:19

I think any changes in the duration of exclusive breast feeding should be from WHO. Also WHO could help find out about this study if it is properly done and see what implications will happen in both developed and developing countries if this study is already published in website.

Nimco Hussein Ahmed

nutrition officer

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28 Oct 2014, 11:49

i have a question how do manage and organize mother support group sessions thank you

Anonymous 2707

Normal user

28 Oct 2014, 13:20

For exclusive breastfeeding; it's 6 months

Nicki Connell

Emergency Nutrition Advisor, Save the Children

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29 Oct 2014, 11:10

Dear Nimco I would like to highlight to you the IYCF-E Toolkit recently developed by Save the Children: https://sites.google.com/site/stcehn/documents/iycf-e-toolkit If you go to: Core Toolkit (English) Folder 0. Overview of IYCF-E Toolkit 'Introduction and Toolkit Framework' This is a table of contents and it will point you in the direction of all documents related to IYCF support groups. In particular you will find resources related to this particular topic here: Key Implementation Resources 2. Programme Planning A. Activities f. Support Groups Also in: References 2. Programme Planning A. Activities d. Mother to Mother Support Groups If you require any further assistance please sen an email to: iycfetoolkit@savechildren.org Many thanks.

Wanyama Norman

Nutritionist/ EDARP

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4 Nov 2014, 07:54

Exclusive breastfeeding should be 6 months, i have seen lots of mother practicing it and the results are amazing; healthy infants.Let WHO give guidance if this should change.

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