Exclusive Breastfeeding For Six Months

Breastfeeding is widely acknowledged as the gold standard for infant feeding. "Exclusive" breastfeeding is undeniably the best of the breast. To mark World Breastfeeding Week this year, and celebrate the international theme - "Exclusive Breastfeeding: The Gold Standard safe sound & sustainable", Women's Health Action has produced a golden bow lapel pin for sale. A leaflet promoting exclusive breastfeeding is being distributed to all new mothers during World Breastfeeding Week (1 August 7 August.)

The theme comes directly from WHO's Global strategy for Infant & Young Child feeding(1).

"As a global public health recommendation, infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age and beyond."

Exclusive breastfeeding means that anything but breast milk given by mouth to a baby - even a teaspoonful of liquid changes the breastfeeding status from exclusive to fully breastfed(2). The most common liquids, other than breast milk, that babies are given within the first 6 months period are: water, teas, juice, formula and baby food (solids) which all compromise the exclusive status. Exclusive breastfeeding is having only breast milk (and medicine as required) with feeds frequently and for unrestricted periods. A mother could give her child a mouth full of water at 2 weeks and then never again give her baby anything other than breast milk for 6 months yet the breastfeeding status for that baby is fully breastfed and not exclusive.

Of course, introducing complementary foods or solids compromises the exclusive status. For a mother the commitment to exclusive breastfeeding is a serious one and it helps to have a sound knowledge of the benefits, risks and consequences associated with the introduction of anything else by mouth.

A literature review, using six months of exclusive breastfeeding as the marker(3), found that in comparing the two groups of babies, those that were not breastfed were:

• About 25% more likely to become overweight or obese
• About 30% more likely to suffer from leukemia
• About 40% more likely to develop type 1 diabetes
• About 60% more likely to suffer from recurrent ear infections
• About 100% more likely to suffer from diarrhoea and
• About 250% more likely to be hospitalised for respiratory infections like asthma and pneumonia (3).

These statistics give clear evidence for encouraging 6 months exclusive breastfeeding.

Easier said than done in a society where bottle feeding and early introduction of solids have become the norm. The well child check done at 4-7 months indicates that the exclusive breastfeeding rate in New Zealand is only 10%(4). To break this norm requires support and encouragement from all sectors of society, not just the health professionals, and opens up challenges for us all.

The challenge for

• the mother is to persevere with initial awkwardness and discomfort.
• family members is to embrace and support breastfeeding instead of rushing for the convenience of a bottle or early introduction of solids.
• employers is to make provisions in the workplace for continued breastfeeding on return to work.
• midwives is to support a mother in labour through contractions to minimise the need for pain relief which interferes with breastfeeding initiation(5).
• health professionals delivering services in many fields is to find solutions in breastfeeding rather than outside of it, to see breastfeeding as part of the solution rather than part of the problem.

Research shows that virtually all women can supply and maintain sufficient milk for 6 months to a normal full term infant and also that early supplementing comes about because of a lack or perceived lack of milk supply(6). Exclusivity works best when breastfeeding is frequent and without prescribed timeframes(7). So, the greatest challenge for women in today's western world is to disregard clocks and respond instead to the hunger and cues of the baby. When breastfeeding is promoted and supported without regard to clocks and times, the 'problem' of milk supply seldom enters the picture.

The societal pressures to stop breastfeeding are enormous. Every time someone says to a breastfeeding mother, "are you still feeding that baby", her confidence is undermined which brings with it the temptation to introduce supplementary feeding before babies are six months old.

Six months exclusive breastfeeding is supported by research but also by common sense. The other major developmental milestones at this time include the appearance of first teeth, the ability to sit up unsupported and the ability to master grabbing objects(8).

The developmental mile stones, the known reduction in health risk and the natural inclination of babies to want to breastfeed all support exclusive breastfeeding as a gold standard that is safe, sound and sustainable in a society that values children. Therefore, this year Women's Health Action is celebrating World Breastfeeding Week with attractive gold lapel badges as a symbol for exclusive breastfeeding (check out below for details) and a simple leaflet "Exclusive Breastfeeding" for all mothers birthing in maternity hospitals throughout the country or attending ante-natal classes during World Breastfeeding Week (August 1-7th.)

If we accept the challenge and go for it, we will reap the rewards. We can be confident that whether we are health professionals, mothers, employers, family members or supportive members of society, our efforts will make a difference.

References

(1)World Health Assembly (2003). Global strategy for Infant and young child feeding. Geneva:World Health Organisation can be down loaded from www.who.int
(2)Ministry of Health (2002). Breastfeeding: A guide to action. Wellington:MoH can be down loaded from the www.moh.govt.nz
(4) Plunket statistics from July 2002 to July 2003
(5)Ransjo-Arvidson, A.B., Mattiesen, A.S., Lilja, G., Nissen, E., Widstrom, A. & Uvnas-Moberg, K. (2001). Maternal analgesia during labour disturbs newborn behaviour: effects on breastfeeding, temperature & crying. Birth 28 (1), 5-12.
(6) Akre, J. (Ed.) (1992). Infant feeding the physiological basis. Geneva: World Health Organization.
(7) Dewey, K. (2001). Guiding Principles for complementary feeding of the breastfed child. Washington: Pan American Health Organisation/WHO.
(8) Berger, K. S. (2001). The developing person through the life span (5th ed.) New York: Worth Publishers
(3)The complete list of references from the campaign:

National Breastfeeding Awareness Campaign Risk Statements References

 

Risk Statements Literature Crileria

 

• Well-designed studies
• New studies published from 1990 onward
• Studies from developed countries
• Breastfeeding duration of at least 6 months
• Sample sizes of 100 children or more

Risk Statements: Children who are not exclusively breastfed for 6 months are more at risk for the following diseases, illnesses, and conditions:

• About 40% more likely to develop type 1 diabetes.
• About 25% more likely to become overweight or obese.
• About 60% more likely to suffer from recurrent ear infections.
• About 30% more likely to suffer from leukemia.
• About 100% more likely to suffer from diarrhea.
• About 250% more likely to be hospitalized for respiratory infections like asthma and pneumonia.

Diabetes

Blom L; Dahlquist G; Lonnberg G (1991). The Swedish Childhood Diabetes Study: A Multivariate Analysis of Risk Determinants for Diabetes in Different Age Groups. Diabetologia 34: 757-762.
Gerstein, Hertzel C (1994) Cow's Milk Exposure and Type I Diabetes Mellitus. A Critical Overview ofthe Clinical Literature. Diabetes Care 17:13-19.
Norris, Jill; Fraser, Scott (1995) A Meta-Analysis of Infant Diet and Insulin-Dependent Diabetes Mellitus: Do Biases Play a Role? Epidemiology 7 (1): 87-92.
Virtanen SM; Rasanen L; Aro A; Lindstrom J; Sippola H; Lounamaa R; Toivanen L; Tuomilehto J; Akerblom HK (1991). Childhood Diabetes in Finland Study Group: Infant Feeding in Finnish Children < 7 Yr of Age with Newly Diagnosed IDDM. Diabetes Care 14: 415-417.
Virtanen SM; Rasanen L; Aro A; Ylonen K; Lounamaa R; Tuomilehto J; Akerblom HK (1992). Childhood Diabetes in Finland Study Group: Feeding in Infancy and the Risk of Type 1 Diabetes Mellitus in Finnish Children. Diabetic Med. 9: 815-819.

Diarrhea

Scariati, Paula; Grummer-Strawn, Lawrence; Beck Fein, Sara (1997). A Longtudinal Analysis and the Extent of Breastfeeding in the United States. Pediatrics, 99, (6): e5-e9
Raisler, Jeanne; Alexander, Cheryl; O'Campo, Patricia (l999). Breast-Feeding and Infant Illness: A Dose-Response Relationship? American Journal of Public Health, 89 (13: 2530.
Beaudry M; Dufour R; Marcoux S (1995). Relation Between Infant Feeding and Infections During the First 6 Months of Life. Journal of Pediatrics, 126: 191-197.

Hospitalization for Respiratory Illness

Bachrach, Virginia; Schwartz, Eleanor; Bachrach, Lela (2003). Breastfeeding and the Risk of Hospitalization for Respiratory Disease in Infancy. Arch Pediatr Adolesc Med, 157: 237-243.
Ball TM; Wright AL (1999). Healthcare Costs of Formula-Feeding in the First Year of Life. Pediatrics, 103: 870-876.
Beaudry M; Dufour R; Marcoux S (1995). Relation Between Infant Feeding and Infections During the First 6 Months of Life. Journal of Pediatrics, 126:191 - 197.
Hoey C; Ware JL. (1997). Economic Advantages of Breast-Feeding in an HMO: Setting a Pilot Study. Am J Manag Care, 3: 861-865.
Howie PW; Forsyth JS; Ogsten SA; Clark A; Florey CD (1990). Protective Effect of Breast Feeding Against Infection. BMJ, 300: 11-16.
Nafstad P; Jaakkola JJ; Hagen JA; Botten G; Kongrud J (1996). Breastfeeding, Maternal Smoking, and Lower Respiratory Tract Infections. Eur Respir J, 9:2623-2629.
Oddy WH; Holt PG; Sly PD, et al (1999). Association Between Breast Feeding and Asthma in 6-Year-Old Children: Findings of a Prospective Birth Cohort Study. BMJ, 319: 815-819.

Leukemia

UK Childhood Cancer Study (UKCCS) BR J Cancer Nov 30, 2001; 85(11): 1685-94.
Bener A; Denic S; Galadari S (2001). Longer Breast-Feeding and Protection Against Childhood Leukamia and Lymphomas. Eur J Cancer 37 (2): 234-238.
Infante-Rivard C; Fortier I; Olsen E (2000). Markers of Infection, Breast-Feeding and Childhood Acute Lymphoblastic Leukaemia. British Journal of Cancer 83 (11): 15591564.
Perrillat F; Clavel J; Auclerc MF; Baruchel A; Leverger G; Nelken B; Philippe N; Schaison G; Sommelet D; Vilmer E; Hemon D (2002). Breast-Feeding, Fetal Loss, and Childhood Acute Leukaemia. Eur J Pediatr 161: 235-237.
Rosenbaum PF, Buck GM, and Brecher ML (2000). Breastfeeding and Childhood Acute Lymphoblastic Leukaemia. Proc Natl Acad Sci USA 77: 7415-7419.
Schuz J, Kaletsch U, Meinart R, Kaatsch P, and Michaelis J (1999). Association of Childhood Leukemia with Factors Related to the Immune System. British Journal of Cancer 80: 585-590.
Dockerty JD, Skegg DCG, Elwood JM, Herbison GP, Becroft DMO and Lewis ME (1999). Infections, Vaccinations, and the Risk of Childhood Leukemia. British Journal of Cancer 80: 1483-1489.
Smulevich VB, Solionova LG, and Beyakova SV (1999). Parental Occupation and Other Factors and Cancer Risk in Children: I. Study methodology and Other Occupational Factors. Int J Cancer 83: 712-717.
Hardell L; Dreifaldt AC (2001). Breastteeding Duration and the Risk of Malignant Diseases in Childhood in Sweden. Eur J Clin Nutr 55: 179-185.

Obesity/Overweight

Gillman, Matthew; Rifas-Shiman, Sheryl; Camargo, Carlos; Berkey, Catherine; Frazier, A. Lindsey; Rockett, Helaine; Field, Alison; Colditz, Graham (2001). Risk of Overweight Among Adolescents who Were Breastfed as Infants. JAMA 285 (19): 24612467.
Hediger, Mary; Overpeck, Mary; Kuczmarski, Robert; Ruan, W. June (2001). Association Between Infant Breastfeeding and Overweight in Young Children. JAMA, 285 (19): 2453-260.
Toschke, Andre Michael; Vignerova, Jana; Lhotska, Lida; Osancova, Katerina; Koletzko, Berthold; von Kries, Rudiger (2002). Overweight and Obesity in 6- to 14-Year-Old Czech Children in 1991: Protective Effect of Breast-Feeding. Journal of Pediatrics 141 (6): 764-769.
Liese AD; Hirsch T; von Muitius E; Keil U; Leupold W; Weiland SK (2001). Inverse Association of Overweight and Breast Feeding as Infants. Intl J Obesity, 25: 1644- 1650.
O'Callahan MJ; Williams GM; Andersen MJ; Bor W; Najman JM (1997). Prediction o Obesity in Children at 5 Years: A Cohort Study. Journal of Pacdiatr. Child Health, 33: 311-316.
Dewey K (2003). Is Breastfeeding Protective Against Childhood Obesity? J Hum Lact. 19 (1): 9-18.

Otitis Media

Scariati, Paula; Grummer-Strawn, Lawrence; Beck Fein, Sara (1997). A Longtudinal Analysis and the Extent of BreastLeeding in the United States. Pediatrics 99 (6): e5-e9
Raisler, Jeanne; Alexander, Cheryl; O'Campo, Patricia (1999). Breast-Feeding and Infan lllness: A Dose-Response Relationship? American Journal of Public Health 89 (1): 2530.
Duncan, Burris; Ey, John; Holberg, Catherine; Wright, Anne; Martinez, Fernando; Taussig, Lynn (1993). Exclusive Breast-Feeding for at Least 4 Months Protects Against Otitis Media. Pediatrics 91 (5): 867-872.
Duffy, L; Faden, H; Wasielewski, J; Wolf, D; Krystofik, D; Tonawanda/Williamsville Pediatrics (1997). Exclusive Breastfeeding Protects Against Bacterial Colonization and Day Care Exposure to Otitis Media. Pediatrics 100:e7.
Owen, Mary Jean; Baldwin, Constance; Swank, Paul; Pannu, Amarjit; Johnson, Dale; Howie, Virgil (1993). Relation of Infant Feeding Practices, Cigarette Smoke Exposure, and Group Child Care to the Onset and Duration of Otitis Media with Effusion in the First Two Years of Life. Journal of Pediatrics 123 (5): 702-711.