Discussions about exclusive breastfeeding date back long before Kramer's article.  It was a hot topic when I was doing my MHS in 1984.  The fight was over "six" versus "four to six" months.  By then before four months was clearly understood as unhealthy.  It is not a new discussion at all.  

In fact, when I was doing my doctoral dissertation my results actually may have added to the push for some of the studies on exclusivity to six months.  My results actually, I think, actually do make an indirect case for maintaining a good solid milk supply from three to six months.  

My results could have been incorrectly interpreted as "supplements between three to six month are associated with better growth."  I worked with a huge data set from Guatamala.  I was about three years too early for the big global push on operations research for iodine deficiency which was what I has proposed.  So I settled on looking at the influence of timing of supplements on growth.  I didn't publish those results in anything other than a FASEB meeting.  I did comparison a) below because almost none of the infants were exclusively breastfed by three months of age.  The distinction between the following three comparisons is incredibly important to interpretation of how supplementation impacts breastfeeding:

a) a comparison between nutrient dense supplementation at a feeding center (likely to be less contaminated with bacteria) and nutrient poor supplementation at home (where access to proper sanitation was limited)
b) a comparison between human milk and nutrient dense supplementation at a feeding center and
c) a comparison between human milk and nutrient poor supplementation at home


My results showed no increase in diarrhea among those who consumed more supplementation at the feeding center. There was an increase in linear growth between 3-6 months with increased consumption of the supplement at the feeding center that was also associated with length at 2 years of age.  No other interval showed that association.  Basically, adding clean supplementation to a situation in which infants were already supplemented with a nutrient poor supplement in an area of poor sanitation was an improvement over the status quo.  

That is not to say by any means that it was ideal or even beneficial.   We have enough studies now to show that had there been enough data on infants who were exclusively breastfed in that environment that those who received more of the supplement from the feeding center would have had higher rates of diarrhea.  In "Mother's Milk and Sewage" my advisor and other researchers showed a 2.5 fold increase in the risk of death in infants who were not exclusively breastfeed even in the households that had clean water and a flush toilet.  

How I interpret my results is that there is a window of opportunity during which we should really provide assistance to women to maintain frequent breastfeeding - and that window is the three to six month interval so that the quantity of human milk is higher.  This is exactly the interval when the 1950s style male-pediatrician-led, never-spend-too-much-time-actually-observing-a-feeding advice is to regiment baby's sleep and feeding cycles into industrial efficiency.  While one can point the finger at work place conditions (as we should), you cannot neglect to look how this pervasive incidious industrialization of infant feeding practices (as if they were factory line workers) has really damaged the development of healthy relationships with food.  Just listen to the middle of the night infomercials in the United States and just about everything (except sleep mattresses) is a walking indictment of how we train our infants to eat.  

As for Kramer, I actually find it amusing that he is cited as having anything to do to contribute to the discussion of exclusivity.  His association style nutritional epidemiology was often a topic of illustration for my dissertation advisor.  Kramer would have failed my advisor's test of understanding the difference between an efficacy and an effectiveness trial.  Kramer never tested "efficacy".  He merely tested the "effectiveness" of a breastfeeding promotion campaign which really wasn't very effective.  Since there was no "exclusively fed formula feeding group" and the "effectiveness" of the intervention was fairly minimal, it is kind of a no brainer that you would have minimal results.  

What would have been more productive with those trials would have been a deeper exploration of why the intervention had minimal impact.  I think the key is in understanding the many societal pressures that occur in the three to six month interval that are DIFFERENT from the societal pressure that may impede the initiation of breastfeeding.  Furthermore, while the workplace environment plays a huge role, there are many other factors that should be addressed simultaneously.

Best, 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