I have not fully analyzed the study that Marko Kerac sent, but of course, I found this fascinating having worked in that world for so long. 

First, I'm not surprised having worked or visited something over 33 countries, I know that there is a lot of malnutrition in the under 6 month olds. I haven't traveled to those places in the last 12 years since my son was born, but I know from the data that used to be published by UNICEF (and seems to have disappeared lately) that the malnutrition rates increased in Africa as the breastfeeding rates decreased.  Everyone said that Ane Veneman should be given a chance as the head of UNICEF, but that SHOULD have been the organization that really tried to preserve breastfeeing during the years when we did discover that formula was not the option to reduce death rates when HIV hit the scene and actually worsened the death rates.  I am still shocked that the international community and/or the media has been so silent about the fact that she is now working with Nestle.  

Second, I wish that you had separated the 0-3 month and the 3-6 month olds.  This is because there is some interesting findings on how growth patterns in those two different groups.  In the Guatemala study, there were some interesting findings about wasting and stunting at different ages on stunting at later ages and responses to supplementary food.  My little piece of research caused some degree of consternation when I presented it at FASEB and I never published it because I thought the findings could be misused similar to the transformation of the recent BMJ opinion piece that concluded "maybe we need to reevaluate offering complementary foods to some breastfed infants before six months" that ended up in the media as "breastfeeding to six months is harmful" in the media. 

I looked at the impact of a complementary feeding program on length during these two intervals.  I found that the greater length gain from 3-6 months of age associated with clean complementary food at a feeding center was associated with greater length at 2 years of age. And like many other studies I found increased risk of diarrhea among those infants that received that complementary food before 3 months of age. This was an area (as with many) where exclusive breastfeeding to 6 months was not that common and contaminated foods were typically offered. The study was not designed to answer the question of the duration of exclusive breastfeeding and predated later studies that showed strong evidence of waiting to 6 months.  Its been so long since I did my research and I haven't thought about it much in years because I felt it could be misinterpreted in ways that might detract from breastfeeding.  I feel strongly that the possibility that the 3-6 month window might be a crucial one for later growth should be looked at carefully.  I believe Chessa Lutter found similar results in the data set in Columbia.  And by this, I mean we need to stop pretending that breastfeeding goes swimmingly well in the developing areas of the world.  The neglect of specific attention to breastfeeding, particularly in Africa really is scandalous.  Breast milk, is the most sterile, nutrient dense complementary food we could provide to these infants. At the time of the Guatemala study, I don't know if there were any programs for increasing milk production other than by supplementing mothers or if there were any programs for donor milk.

Third, I am not surprised by the findings in that you covered an interval where the velocity in weight changes -- but the overall weight is higher among the samples of infants that were selected as healthy breastfeeders.  We know the weight velocity slows for 3-6 month olds, but the actual weight didn't drop down that much.  

Anyway -- I think this study argues for a renewal of attention to the crucial problems of breastfeeding in developing areas.  And by this, I think we should pay more attention to breastfeeding that merely promoting it.  I know in the Democratic Republic of Congo that hypothyroidism is common in the North East.  I have no idea how well the iodization programs have managed under the current shaky political situation, but I do know that there were some villages where goiter rates were essentially 100% and cretins were common.  I cannot imagine that the hypothyroidism in that areas is NOT having an impact on milk production and in other areas where pockets of iodine deficiency may still persist.  Ditto for obesity.  Even back in the 1980s in that area of Africa there was a U-shaped curve of marasmus AND kwashiorkor and a lot of obesity later in life, particularly among women. There are many developing areas where there is this U-shaped curve.  We now know that obesity too can influence milk production.  

I really feel that we have been hit by a second wave of the formula industry running rampant in the developing world using HIV as an excuse and I cannot help but feel that the conflicts of interest of allowing someone with such clearcut conflicts of interest to run UNICEF -- (and I'm still waiting for an outcry about the fact that she is with Nestle now) to decimate James Grant's inclusion of breastfeeding as a primary intervention for child survival has left us 20 years behind the curve of addressing the malnutrition among under six month olds.

This is a quick reaction to this paper.  I need to study it and go back to my dissertation and think about it all some more.

Sincerely, 

Susan E. Burger, MHS, PhD, IBCLC

             ***********************************************

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
2. To start it again: set lactnet mail
3. To unsubscribe: unsubscribe lactnet
4. To get a comprehensive list of rules and directions: get lactnet welcome