A history lesson. I realise that many Lactnetters have not read Breastfeeding Matters (first published in 1985 and fourth revised edition 1998) or this discussion would be very different. As for when it was first agreed that babies be given nothing but breastmilk for the first 6 months,  that advice goes back to the early 20th century, when educational diet was to be started after 6 months and before 9 months, and then between 9 and 12 months a baby moved on to real foods so as to be weaned by 12 months (or later than that if 12 months was in summer.) My mother followed that pattern with me in 1945. WHO was a reluctant and late convert to the importance of exclusive breastfeeding, having to do multi-country studies before adopting it as policy. There is NO comparable research to show that 6 months' exclusive formula feeding is safe. It is assumed to be because breastfeeding is proved to be.

I enclose a relevant excerpt from ch 13 of the book in 1985/1998:
"...This inertia/laziness factor is sometimes tacitly recognised. In asking about what instructions were given on feeding during gastroenteritis and fasting before anaesthe­sia, I have often been told that this doctor/hospital does not discriminate between human milk and other forms of milk because ‘it’s easier and less confusing’ theoretic­ally for mothers. Poor dim creatures that we are, there are not many of us incapable of recognising the difference between breastfeeding and bottle-feeding, and I would suggest that it is not terribly difficult to write instructions on what to do in either case, and why. However, a clear-cut discrimination on these grounds would start mothers thinking and probably asking awkward questions for staff to handle, such as ‘If I had been breastfeeding would my baby have become sick this time?’, ‘Would it help my baby to get better if I could get her some breast milk?’, ‘Do you have human milk available for sick babies?’, and so on.

We must insist upon this sort of clear-cut distinction between human milk and its artificial substitutes, and not permit breastfed babies to suffer because of some desire to average it all out and keep everyone happy. This moral cowardice masquerading as pragmatism is best exemplified by the current recommendations for the introduction of solid foods. The American Academy of Pediatrics Committee on Nutrition made a recommendation in 1980 that babies be introduced to solid foods between four and six months of age, after previously exclusive breast milk or formula-feeding. As a later letter pointed out,[i] their reasoning was: disappearance of the extrusive reflex at four to five months; ability to indicate satiety by five to six months; development of appreci­able IgA levels by seven months. A more appropriate recommendation (but unpopular) would thus have been to introduce other foods no earlier than six to seven months. This squares with Kajosaari and Saarinen’s work on allergy,[ii] where exclusive human milk feeding to six months rendered negligible the rates of food allergy at 12 months. For infants given solids between three and 6 months, the incidence was 37 per cent. For infants given solids after six months, it was 7 per cent; the children had strong family history of allergy, yet only 14 per cent (compared with 35 per cent) had eczema at 12 months. Clearly six months’ exclusive human milk feeding must be the minimum goal.

But why exactly did the AAP Committee recommend between four and six months? A letter from the Committee Chairman made this clear: because of the pos­sible risks of prolonged exclusive artificial feeding. He said, ‘Trying to convert from previous practices of feeding solids at 1 month of age to the present recommendations must be done step-wise. A compromise was felt to be necessary. For breastfed infants there seems no advantage and some disadvantage[iii] to early supplements. When one uses an artificial formula, no matter how good, one must beware of possible missing ingredients. Weighing advantages and disadvantages, the Committee on Nutrition felt that 4 to 6 months of age was reasonable with present evidence.’[iv]

But why penalise breastfed infants because of ‘possible missing ingredients’ in formula? Why not have two distinct sets of recommendations for the breast- and bottle-fed infant?

· Exclusive human milk feeding for so long as growth and health remains good – in Dr Barness’s own case, this was 12 months, and that is not exceptional. Only a genera­tion ago many mothers took it for granted that nine months was the age for giving other foods, and many thriving Australian babies are exclusively breastfed for similar periods.

· Exclusive use of a new, yet-to-be developed low-allergy formula[v] for infants unable to be given human milk, with the addition of other foods after three or four months to try to guard against possible unsuspected deficiencies in the formula, industrial accidents, and the like.

Why not a two-part policy, for such different groups of babies? This is clearly the logical solution, but it would cause mothers to ask questions about the ‘equivalence’ of formula. It would enrage the manufacturers who contribute so generously to the Acad­emy. It would upset the status quo. Paediatricians really ought to ‘eschew endorsement for the sake of palatability [sic] of popular trends, and to present unpopular recommen­dations if they can be justified and if they offer the opportunity to lead a misdirected community toward more desirable health care patterns’, as one so aptly put it.8 They ought to, but they often do not.[vi] This is a marker of how corrupted medicine has been by its long association with commerce."

References on request. If enough requests, will post to Lactnet. Back to finalising next book. 

Maureen.
             

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