To find out how many babies are being exclusively breastfed at a given time,
I am only concerned with the recent past, like a week or a month or three
months - or sometimes just the previous 24 hours, depending on what my
dependent variable is. This will tell me what the baby is being fed now, but
it will not reveal to me that the baby may have been supplemented at some
point in the more distant past. 

For epidemiological research one is usually interested in whether a group
has been exposed to a particular factor that affects health, and often it is
a supposed risk factor one is looking at.  What if we re-framed the issue to
one of exposure to breastmilk substitutes?  The two broad categories would
be 'never exposed to breastmilk substitutes' and 'at least one exposure to
breastmilk substitutes'.  It could be further refined to be able to quantify
the exposure, and to pinpoint it in time, perhaps in terms of percentage of
total intake and onset and duration of the exposure in days or weeks.

Since breastfeeding is not what we call risk-taking behavior, it seems to me
that in studies looking at the ill effects of exposure to breastmilk
substitutes, that should be the independent variable, and not 'exposure to
breastfeeding'.  It might serve to open eyes a bit more too, when it turns
out that even a small exposure to a breastmilk substitute in the first few
days reduces the chance that a baby will be exclusively breastfed after a
few months, and shortens the total duration of breastfeeding, or that it
increases the likelihood that the child will suffer illness requiring
hospitalization in the first year of life.  

Instead of touting breastfeeding as the all-protective factor that prevents
anything bad from happening to the child, we could point up the risk of
using anything else.

I'm faced with this daily, when I discharge someone from the hospital who
leaves fully breastfeeding, despite the baby having been supplemented at
some point during the postpartum stay.  We specify baby's diet at discharge,
but can add in free text that the baby was given something else on day 1 or
2 or whenever it was.  That way, those following the baby know that it
belongs in the risk group category 'ever fed a breastmilk substitute' but
that at discharge from hospital the mother was not supplementing.

Rachel Myr
Kristiansand, Norway

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