Ted Greiner says it's fine for me to submit this to Lactnet.. his comments
are at the very end..
Jan Cornfoot [log in to unmask]
Brisbane, Australia
From: Ted Greiner <[log in to unmask]>
Sent: Saturday, 27 November 1999 9:57
Subject: UNICEF statement on the duration of exclusive breastfeeding
Duear Friends,
UNICEF has just issued the statement below and agreed that I could share it
with our WABA email list. They also agreed that I could add the comment you
will find at the end:
"UNICEF's recommended length of exclusive breastfeeding
Note prepared by Lida Lhotska and Helen Armstrong, 22 November 1999
We appreciate the opportunity provided by the Breastfeeding Topics web page
(http://www.bftopics.org/) to clarify the recommended timing of
complementary feeding, and thereby the length of exclusive breastfeeding.
It is important to make a distinction between public health policy
recommendations, and individualised case management.
UNICEF, together with the World Health Assembly (WHA) and many governments,
maintains that the infant feeding recommendations in general are for
breastfeeding to be exclusive for about 6 months. In public health policies
and communication, what will produce the highest attainable standard of
health for the majority of infant are what determine the recommendations.
For example, we urge "Breast is best" without adding that in a few cases
such as maple syrup urine disease or PKU, other feeds could be medically
necessary.
Adaptation to the needs of the individual who represents a less usual case
is always to be done one by one, through individualized case management.
This is clearly stated in WHO/UNICEF Integrated Management of Childhood
Illness (IMCI) materials, where it is explicitly stated that "Most babies do
not need complementary foods before 6 months of age."
In the case of poor growth or other signs that breastfeeding is not going
well in the early months, one would first correct the breastfeeding pattern,
getting rid of other feeds such as water, making breastfeeding exclusive and
frequent again, observing the effectiveness of suckling and who terminates
the feed (baby or mother), eliminating any use of bottles or pacifiers, and
generally making breastfeeding management as good as possible. Only after a
week or two of well supported exclusive breastfeeding, in the optimal
pattern, would one want to consider if there might be a need to start giving
some complementary food to the child over four months of age but not yet six
months.
There are three signals of a possible need for early complementation in
such an infant who is effectively and exclusively breastfed and is over
four months but not yet six months. These are specified in the IMCI
materials as follows, with bracketed explanations added by ourselves:
"The mother should only begin to offer complementary foods if the
child:
- shows interest in semisolid foods [e.g. reaching for them
and shouting]
- appears hungry after breastfeeding [on demand, without
any limits] or
- is not gaining weight adequately.
The mother should give the complementary foods 1-2 times daily after
breastfeeding to avoid replacing breastmilk." (IMCI Counsel the Mother,
WHO/UNICEF 1995, p. 5)
UNICEF recommendations in this as in other aspects of infant feeding are
guided, so far as possible, by current scientific and clinical evidence. A
recent key article is by Cesar Victora et al: Impact of breastfeeding on
admission for pneumonia during postnatal period in Brasil: nested
case-control study. Brit Med J 1999;318:1316-1320.
In addition, WHO's publication Complementary Feeding of Young Children in
Developing Countries (WHO/NUT/98.1) reviews current scientific knowledge.
The authors of this review conclude that "full term infants with appropriate
weight for gestational age should be exclusively breastfed until about six
months of age." (p. 167) The more recent work of Dewey, Cohen et al in
Honduras further indicates that no growth advantage is seen even in Low
Birth Weight infants when complementary foods are introduced before six
months (Am J Clin Nutr 1999; 69(4)).
There are a few colleagues who omit these key references from their
discussions of the timing of complementary feeding, and insist on
recommending complementary foods from 4 months or using the outdated
terminology of "4-6 months." This phrase, used in the Innocenti
Declaration of 1990, predates the evolution of knowledge about the damaging
effects of early complementation upon both breastmilk intake and infant
morbidity. Current knowledge is adequately represented in the up to date
"about six months" phrasing. We could not identify any current studies that
would justify the general recommendation of complementary foods from 4 or 5
months; all newer studies suggest that such a recommendation would have a
deleterious effect on child health without any compensating advantage in
growth.
It is of course important to recall that according to international
definitions, an infant who receives expressed breastmilk in the mother's
absence is exclusively breastfed. (WHO/CDD/SER/91.14) UNICEF and WHO are in
agreement that such milk should be given by open cup, not by feeding bottle,
and this helps to ensure that the infant will suckle effectively at the
breast when her or his mother returns.
We would point out that since 1993 key UNICEF publications have recommended
exclusive breastfeeding as follows:
"Breastmilk alone is the best possible food and drink for a baby.
No other food or drink is needed for about the first six months of life". A
variety of additional foods is necessary when a child is about six months
old, but breastfeeding should continue well into the second year of a
child's life and for longer if possible." (Facts for Life, UNICEF 1993)
The latest UNICEF publication on infant feeding repeats this recommendation:
"Babies should be exclusively breastfed - meaning that they receive nothing
but breastmilk, not even water - for about the first six months of life.
Except in the rarest cases, no additional foods or fluids are necessary, and
they can be harmful - introducing germs, triggering allergies and filling
the stomach so that the infant takes less breastmilk. Breastfeeding should
be sustained until the baby is at least two years old, but beginning at
about six months breastmilk should be complemented with appropriate solid
foods."
(Breastfeeding: foundation for a healthy future. UNICEF 1999)
Readers may request these publications from their UNICEF country offices or
National Committee for UNICEF.
We would also mention that two Facts for Feeding leaflets from the Linkages
project contain helpful current information, including the recommendation of
breastfeeding exclusively for about six months. They cover the first six
months and the period of 6-24 months and may be obtained from
<[log in to unmask]> if they cannot be downloaded from the Linkages website.
These leaftlets have been sent with our endorsement to all UNICEF offices."
[The point I (Ted) would add is that the definition of what constitutes "not
gaining weight adequately" in breast-fed babies is not always well
understood and indeed will be clearer once WHO has completed its ongoing
multi-center study of the growth of predominantly breast-fed babies. But
health workers ought perhaps to be warned that a seeming reduction in the
velocity of growth during the period 3-6 months may in many cases be at
least partly due to problems inherent in using the WHO (NCHS) growth curves
to monitor growth in breast-fed babies. These standards were based on babies
who were largely bottle fed and we now know that their pattern of growth is
different.
With all best wishes,
Ted Greiner, PhD
Coordinator, WABA Research Task Force]
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