January 2011: Media has been covering an article published in British Medical Journal “Six months of exclusive breast feeding: how good is the evidence?
Found at: http://www.bmj.com/content/342/bmj.c5955.full
RESPONSES:
1. Randa Saadeh
World Health Organization
WHO's global public health recommendation is for infants to be exclusively breastfed for the first 6 months of life to achieve optimal growth, development and health. Thereafter, infants should be given nutritious complementary foods and continue breastfeeding up to the age of 2 years or beyond.
WHO closely follows new research findings in this area and has a process for periodically re-examining recommendations. Systematic reviews accompanied by an assessment of the quality of evidence are used to review guidelines in a process that is designed to ensure that the recommendations are based on the best available evidence and free from conflicts of interest.
The paper in this week's BMJ is not the result of a systematic review. The latest systematic review on this issue available in the Cochrane Library was published in 2009 ("Optimal duration of exclusive breastfeeding (Review)", Kramer MS, Kakuma R.
The Cochrane Library 2009, Issue 4). It included studies in developed and developing countries and its findings are supportive of the current WHO recommendations. It found that the results of two controlled trials and 18 other studies suggest that exclusive breastfeeding (which means that the infant should have only breast milk, and no other foods or liquids) for 6 months has several advantages over exclusive breastfeeding for 3-4 months followed by mixed breastfeeding. These advantages include a lower risk of gastrointestinal infection for the baby, more rapid maternal weight loss after birth, and delayed return of menstrual periods. No reduced risks of other infections or of allergic diseases have been demonstrated. No adverse effects on growth have been documented with exclusive breastfeeding for 6 months, but a reduced level of iron has been observed in developing-country settings.
2. Comment by Adriano Cattaneo to the BMJ Rapid Response (Adriano Cattaneo is Consultant Epidemiologist and Co-ordinator of the Unit for Health Services Research and International Health, Institute of Child Health “IRCCS Burlo Garofolo”, Trieste, Italy, a WHO Collaborating Centre for Maternal and Child Health.)
The evidence provided by Fewtrell and collaborators to challenge the WHO 6-month recommendation is no better than the one provided by WHO. It is in fact slightly worse. The WHO recommendation is based on two RCTs and 16 observational studies. All the studies published after 2001 on infection, nutritional adequacy, allergy and coeliac disease, and outcomes in the longer term that Fewtrell and collaborators cite to question the 6-month policy are observational. The only two RCTs they cite are ongoing and can not be used to argue against the WHO 6-month policy. Until further evidence becomes available, I prefer to stand by the WHO recommendations (and hope the UK and Italian DoH will agree with me). Incidentally, the WHO recommendation has never been meant to apply to all infants. It is a public health recommendation to be used for national and professional policies and regulations (for example, on labelling of baby foods). Infants in fact do not wake up the day they reach six months and ask for solids!!! Readiness to eat the first solids is distributed as any other biological variable, a Bell shaped curve that in my opinion (because no research is available to know the real shape) has a mode at six months and is skewed to the right (i.e. more infants are ready after than before six months). Why don't we concentrate on physiology and neuromuscular development to advise mothers on when to start solids, instead of wandering in search of doubtful evidence? Finally, I am amazed by the rapid spread into the popular press and media of the questionable messages posted by Fewtrell and collaborators in their paper. Less than 24 hours after publication, newspapers in Italy (and I guess in UK and other countries; TV will follow suit) are already talking about a "new study" showing that exclusively breastfeeding infants to six months may be dangerous. Am I wrong if I ask the authors to make a quick public statement to transparently say that theirs is not a "new study" but just a respectable opinion based on shaky grounds?
3. From Francesco Branca - Head of Nutrition at WHO.
WHO's global public health recommendation is for infants to be exclusively breastfed for the first 6 months of life to achieve optimal growth, development and health. Thereafter, infants should be given nutritious complementary foods and continue breastfeeding up to the age of 2 years or beyond.
WHO closely follows new research findings in this area and has a process for periodically re-examining recommendations. Systematic reviews accompanied by an assessment of the quality of evidence are used to review guidelines in a process that is designed to ensure that the recommendations are based on the best available evidence and free from conflicts of interes
The paper in this week's BMJ is not the result of a systematic review. The latest systematic review on this issue available in the Cochrane Library was published in 2009 ("Optimal duration of exclusive breastfeeding (Review)", Kramer MS, Kakuma R.
The Cochrane Library 2009, Issue 4). It included studies in developed and developing countries and its findings are supportive of the current WHO recommendations. It found that the results of two controlled trials and 18 other studies suggest that exclusive breastfeeding (which means that the infant should have only breast milk, and no other foods or liquids) for 6 months has several advantages over exclusive breastfeeding for 3-4 months followed by mixed breastfeeding. These advantages include a lower risk of gastrointestinal infection for the baby, more rapid maternal weight loss after birth, and delayed return of menstrual periods. No reduced risks of other infections or of allergic diseases have been demonstrated. No adverse effects on growth have been documented with exclusive breastfeeding for 6 months, but a reduced level of iron has been observed in developing-country settings.
4. From Elisabeth Sterken, INFACT Canada
Introduction of solids is in actual fact a learing and discovery of the tastes, textures, colour and feel of food and should do little breastmilk replacement at 6 months. If infants are started on the rice starch with iron fillings and a few B vitamins the replacement of valuable breastmilk is of concern.
-5 From Patti Rundall, Baby Milk Action UK.
Bear in mind the following:
· Three of the authors receive funding from the baby food industry (Mary Fewtrell, Alan Lucas and David Wilson)
· This is not a report on new data.
· The argument to introduce solids at 4 months to prevent coeliac disease and allergies was summarised by ESPGHAN in late 2009 and were considered by many to be flawed. see our press release: http://www.babymilkaction.org/press/press23dec09.html . At present it is observational only and there are RCTs in progress; pre-empting the results of these seems foolish.
· The UK Scientific Committee on Nutrition (SACN) and the Committee on Toxicity ( COT) are reviewing the evidence on solid foods and coeliac disease. The draft opinion is NOT FINAL BUT Is on the SACN website with the Agenda papers for next week's SMCN meeting. See paper SMCN/11/01 downloadable from http://www.sacn.gov.uk/meetings/sub_groups/maternal_child_nutrition/190…
· SACN use international growth charts to describe the optimal pattern of infant growth in the UK (UK-WHO charts). The mean age at introduction of solids to this cohort of breastfed infants was 5.4 months (or "..about 6-months").
· The UK policy is to introduce at around 6-months and progress responsively, in line with individual babies' progress and acceptance. Not all babies need solids at the same time: in every aspect of infant development there is a wide range of normal. Very importantly the introduction of the new policy in 2003 was associated with a marked reduction in the numbers of mothers giving solids very early (i.e. before 4-months). Since almost everyone agrees that very early introduction carries greater risk (particularly of coeliac disease) the UK policy could be considered from this perspective a success.
With thanks to Betty Sterken of Infact Canada for comments 2-5..
Basically - the recommendation is exclusive breastfeeding until about 6 months. And like any guideline this was meant to be a GUIDE. There is nothing new at this point to suggest a change in this guideline.