Breast Best for Six Months Questioned

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A recommendation from the World Health Organization that women exclusively

breast feed their infants for six months lacks support from randomized

clinical trials -- and warrants a critical reappraisal in light of recent

contradictory findings, authors of an evidence review concluded.

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The 2001 WHO global recommendation for six months of exclusive breast

feeding was based largely on a systematic review that included only two

randomized clinical trials (Kramer MS, Kakuma R *WHO* 2002), and since that

time conflicting evidence has included rising rates of food allergy in

developed countries, according to Fewtrell, MD, of the University

College London Institute of Child Health in London, England.

However, writing online in the *BMJ,* Fewtrell and co-authors emphasized

that they were not calling for a reevaluation of the evidence to support

breast feeding itself -- that evidence is extensive, they stressed.

In their review, the researchers urged only for a reappraisal of those data

used to support the WHO recommendation for six months' exclusive breast

feeding -- which the agency defines as excluding solid foods or any other

fluids (including infant formulas) except medicines, vitamins, and minerals

before six months of age.

" In the West, exclusive breast feeding for six months is linked to a reduced

risk of infection, " Fewtrell and co-authors wrote. " Nevertheless, the

studies are observational and some evidence suggests that introducing solids

(rather than formula) may not significantly affect risk of infection. By

contrast, exclusive breast feeding to six months raises concerns. "

Those concerns include an increased risk of iron deficiency anemia, a higher

incidence of food allergies, and a higher risk of celiac disease.

The systematic review underpinning the WHO advice had four principal

conclusions to support the agency's recommendation for six month's exclusive

breast feeding:

- There were no apparent growth deficits

- No evidence of an association with allergy

- Poorer iron status

- Delayed return of menses and more rapid postpartum weight loss in

mothers

The U.S. and about two-thirds of European countries elected not to follow

the WHO recommendation. In 2003, however, the U.K. health ministry decided

to comply with the WHO advice.

" Substantial evidence indicates that early nutrition has profound

implications for long-term health by programming aspects of subsequent

cognitive function, obesity, risk of cardiovascular disease, cancer, and

atopy, " Fewtrell and co-authors wrote.

" However, the evidence base supporting a major population-wide change in

public policy underwent surprisingly little scrutiny, " the researchers

noted.

Moreover, the evidence from the systematic review that preceded the WHO

recommendation included contradictory findings.

For example, an observational study in Belarus showed a significant

reduction in the risk of gastroenteritis among infants following a program

to promote exclusive breast feeding (*Am J Clin Nutr* 2003; 78: 291-295).

In contrast, a systematic review of 33 studies found no compelling evidence

to support a delay in the introduction of solids in breast-fed and

formula-fed infants from four to six months (*Eur J Clin Nutr* 2001; 55

:309-320).

The authors suggested three prerequisites for adoption of a policy of

exclusive breast feeding for six months:

1. Assessment of the adequacy of data to support the policy, followed by

an evidence-based approach to appraisal of scientific data

2. Comprehensive assessment of the risks and benefits

3. An auditing mechanism to detect adverse population effects

In a statement, Fewtrell and colleagues said they supported six months of

exclusive breast feeding in less developed countries where access to clean

water and safe weaning foods is limited and there is a high risk of infant

death and illness.

The authors also emphasized that they fully support exclusive breast feeding

early in life -- and despite their call to reappraise the WHO recommendation

they stressed that " it is important not to confuse the evidence for

promoting six months' exclusive feeding with that for breast feeding itself,

which is extensive. "

*Primary source: *BMJ

Source reference:

Fewtrell M, et al " Six months of exclusive breast feeding: How good is the

evidence? " *BMJ* 2011; DOI:10.1136/bmj.c5955.

<http://www.bmj.com/content/342/bmj.c5955.full>

--

Ortiz, MS, RD

*The FRUGAL Dietitian* <http://www.thefrugaldietitian.com>

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