Recommended Duration of Exclusive Breastfeeding and Age of
Introduction of Complementary Foods - A Review
Arun Phatak, MD (Ped) and Arun Gupta, MD, FIAP
INTRODUCTION
Breastfeeding has been going on since mammals evolved 230 million years ago on our
planet. It was then the obligatory way to feed the young ones. Artificial feeding came into
vogue with industrial revolution in the 19th century. The dairy business flourished with
advances in the processing and preserving the milk and the development of special
formulas for special needs (e.g. preterm babies). Aggressive promotion, not only enticed
mothers into preferring the bottle to the breast but even made people believe that
“formula feeding is so simple, safe and uniformly successful that breastfeeding no longer
is worth the bother”1.But scientific research during the last three decades has clearly
proved that breastfeeding provides the most suitable nutrition to the baby, protects it
against infections , allergies and asthma, promotes physical, physiological, motor-mental
and psycho-social growth and development and gives protection against some adult
diseases such as diabetes, hypertension, ischemic heart disease and some forms of
malignancy2. In addition, it benefits the mother in various ways like reducing anemia and
breast and ovarian cancers, saves money for the family and the nation, helps fertility
control and is eco-friendly3.
In this paper, we review the current scientific literature on breastfeeding and
complementary feeding that leads us to draw a policy recommendation of BPNI to enable
all concerned working on this issue to make use of this paper to develop local guidelines
. Besides this, it also addresses the issue of exclusive breastfeeding for working women
and the need to have special growth reference standards for breastfed children.
1
EXCLUSIVE BREASTFEEDING and ITS DURATION
With much of research into benefits of breastfeeding reported in 1980s to reposition
breastfeeding, a new set of definitions evolved that included ‘exclusive breastfeeding’,
which means that the baby receives nothing else other than breastmilk. It was well
established that exclusive breastfeeding is the normal way to feed young babies. This
took about a decade for this definition to be understood and still to make a it a practice, it
requires a great effort in a bid to increase the percentage of babies who are exclusively
breastfed during first six months of life.
It has been observed that the beneficial effect of breastfeeding is maximum when it is
exclusive4.
However, there is some confusion about the duration of exclusive
breastfeeding. A general recommendation for introducing complementary foods between
4-6 months dates back to the Innocenti Declaration of 19905a. This has led many careproviders to recommend complementary foods at 4 months of age. Many mothers
interpret this as 4th month and introduce complementary foods on completion of 3
months. Since the Innocenti Declaration, a number of papers have been published which
suggest that babies should be breastfed exclusively until about six months of age and that
there is no growth advantage if complementary foods are introduced early. This is true
even for the low birth weight babies. Some of these papers are reviewed here.
Guldan and his associates6 observed in rural Sichuan infants that not feeding rice before
seven months of age and not giving commercial supplements was associated with better
growth.
Diaz and his coworkers7 followed the physical growth of 1217 infants from birth to 12
months; 100% of these were exclusively breastfed for one month, 63% for six months
and 24% for 12 months. They concluded that breastmilk is sufficient to support adequate
infant growth during the first six months of life and that supplements need not be
recommended before six months.
Lartey and others8 followed 216 normal Ghanian children from one month of age to 18
months. They observed that the rates of diarrhoea increased if the complementary foods
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were introduced between four and six months. They stressed that introducing
complementary feeding after six months of age improved growth by lessening morbidity.
Dewey and coworkers9 compared low birth weight term babies (1500-2500 G) who were
exclusively breastfed for six months with those exclusively breastfed for four months and
then given complementary foods twice daily while continuing breastfeed. They found no
significant difference between groups in weight and length gain during the intervention
period or later up to 12 months age. Early introduction of complementary foods
decreased the breastfeed intakes. Similar observations were made in earlier studies also 10,
11
. Hop et al12observed that early introduction of complementary feeds was associated
with poorer growth.
Vestgaard and co-workers13 followed 1656 Danish infants from birth and assessed the
development of some selected milestones around the age of 8 months. The sample was
divided into four groups on the basis of the duration of exclusive breastfeeding (0-1,23,4-5, >6months) and was adjusted for social and other confounding factors. Those
predominantly breastfed for six months or more were found to be 1.4-2.5 times more
likely to have attained the selected milestones than those with least breastfeeding.
A meta-analysis of 20 studies14 distributed the sample into five groups on the basis of the
duration of predominant breastfeeding (4-7,8-11,12-19,20-27 and >28 weeks) and
compared their weighted means with those of predominantly formula fed infants. The
breastfed babies in each group had significantly higher levels of cognitive function and
the benefits increased with the duration of breastfeeding. The preterm babies derived
more benefits from breastfeeding than the full term babies.
UNICEF (UNICEF, Nutrition Section, NY 22 Nov. 99) could not identify any current
studies that would support introduction of weaning foods from 4 or 5 months while there
are reports of higher incidence of infections and allergies8,12-17 due to early initiation of
weaning foods and has no compensating advantage in growth.
The World Health Assembly resolution (WHA 47.5,1994) urged Member States for fostering
complementary feeding practices from about six months and further WHA resolution 49.15(1996)
reaffirmed this. The WHO however, recommends that infants should be fed exclusively on breastmilk from
birth to 4 to 6 months (WHO: Infant Feeding Recommendations 11 Nov 1999). In the opinion of WHO
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“although, future scientific information and better understanding of variable impact of individual and
population circumstances may well warrant a change one day, present scientific evidence confirms the
suitability of WHO’s long standing infant feeding recommendation based on initial technical review and
discussion in 1979”. But on 13-17 March 2000, twenty consultants had gathered in Geneva for Technical
Consultation to assist WHO and UNICEF on Infant and Young Child Feeding. They recorded that during
the last 10 years after Innocenti Declaration, sufficient scientific (including epidemiological) evidence has
gathered for changing the recommended duration of exclusive breastfeeding to about six months. They
requested that this statement be included in the official published report of the proceedings of this
Technical Consultation. This, however, is only the opinion of the experts but not an official document of
the WHO.
During the last three years, many organizations have recommended exclusive
breastfeeding for six months or for about/around/at least six months. These include
World Alliance for Breastfeeding Action(WABA) and International Baby Food Action
Network (IBFAN), the two key international organizations working on breastfeeding and
related issues. Other organizations like INFACT Canada, La Leche League International,
Nursing Mothers’ Association of Australia, Wellstart International, Linkages Project:
Academy for Educational development, American Academy of Pediatrics (AAP) and
Indian Academy of Pediatrics (IAP) also endorse similar recommendations. By now, the
policy of exclusive breastfeeding for about six months is accepted in 61 countries (Naylor
A: Statement circulated at the Global Technical Consultation on Infant and Young Child
Feeding , March 2000, Geneva)
Most of the recommendations use a general term like “around”, “about”, “at least” so that
introduction of the complementary foods could be a little earlier or later depending on the
situation. After all it cannot be exactly on the next hour or day of completing six months!
The benefits of exclusive breastfeeding for six months are likely to be much more to
infants at high risk (e.g. preterm and those staying in unhygienic environment) than full
term babies of affluent class staying in clean homes. Except in the rarest cases, no
additional foods or fluids are necessary and in fact they can be harmful, introducing
infection, triggering allergies and filling the stomach so that the infants take less
breastmilk.18, 19
COMPLEMENTARY FEEDING
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Beginning at ‘about six months’, breastfeeding should be complemented with appropriate
solid foods. Complementation and replacement of breastfeeding are two separate
components of introducing complementary foods. It is important to avoid replacement of
breastmilk. The additional feed should not be so much that the breastmilk production is
reduced20. The solid foods should be introduced gradually but breastfeeding continued as
often as before. Functional maturation of the neurological, gastrointestinal and renal
systems influence the possibility of successful feeding at different ages21. By the age of
six months the gastrointestinal functions are adequate to deal with the weaning foods
while the kidneys can easily handle the solute load especially under conditions of low
fluid intake. Mashed and chopped foods are acceptable between 7 and 12 months while
family foods are acceptable usually after 12 months of age. The complementary foods
should be prepared fresh from the usual home foods22.
During the initial period, the complementary foods should be given one or two times after
the breastfeeding and not in its place. By 8 months the child should receive
complementary foods between breastfeed at least three times in a day and at least 4 times
a day in the second year. Flavor, aroma, consistency and variety affect the intake of
complementary foods.
The prospective growth enhancing effect of breastfeeding continues into the second year.
Breastfeeding should therefore be sustained in the second year but in the low
socioeconomic community in developing countries, child survival may require mother’s
milk through the third year of life23-26
GROWTH STANDARDS FOR BREASTFED BABIES
In 1983, WHO recommended health standards established by the National Center of
Health Statistics (NCHS) as best suited for international reference27. The Indian Academy
of Pediatrics (IAP) recommended the 50th centile of the Harvard standard for weight as
the standard reference weight (SRW) and 80% of it as the lower limit of normal 28.
Although the recommendation was with an objective of bringing uniformity in the
grading of protein energy malnutrition, the charts are routinely used in assessing the
weights of all children. The lower limit of normal (80% of SRW) lies between the 3rd and
5
5th centiles of the Harvard Standard, which means that in practice, the IAP accepted the
Harvard charts as reference charts.
Studies conducted in various countries, affluent as well as developing6, 7,29-33, reveal that
growth curves of breastfed children differ from the NCHS curves. The NCHS charts
represent children with restricted genetic and ethnic background (Caucasians from
Europe and America) and children who were mostly bottle -fed21,
34,35
. Even the
recommended dietary allowances (RDA) are based on such children. It is now known that
the energy intake of the breastfed infants is often less than the RDA36. Even after the age
of six months, when other foods comprise an increasingly large proportion of the total
intake, the energy intake of the breastfed infants is low compared to that of the formula
fed, even when the quality and quantity of the food offered is similar37. When breastfed
infants are assessed using the NCHS charts, they are likely to be mistakenly identified as
faltering and complementary food introduced earlier than necessary. The need to have
new growth charts based on the breastfed infants belonging to the upper socioeconomic
strata is obvious (WHO Working Group on Infant Growth, WHO/NUT/94-8. Geneva
1994). This should be treated as a top priority in research related to breastfeeding. It is
not difficult. At least one hospital in India32 is using in the follow-up clinic its own charts
for weight, length and weight for length established on breastfed infants. A WHO
sponsored Multicenter growth reference study is underway, it is likely to give us
reference growth standards for breastfed children in a couple of years.
EXCLUSIVE BREASTFEEDING FOR WORKING MOTHERS
The ILO Maternity Protection Convention 191, 2000 recommends provision of paid
maternity leave for 18 weeks. This does not facilitate exclusive breastfeeding for six
months. An infant who receives only expressed breastmilk in the absence of the mother is
considered exclusively breastfed (WHO/CDD/SER/91.14). ILO convention also
recommends provision of breastfeeding breaks and facility for breastfeeding and for
expression of breastmilk at the workplace. Unfortunately, these recommendations are
rarely followed.
6
Another way to facilitate exclusive breastfeeding for about six months is to extend the
maternity leave to about six months. Pandit Jawaharlal Nehru had said that ‘A nation
marches on the tiny feet of its children’. Ensuring exclusive breastfeeding for about six
months is an important initial step towards attaining healthy future for the nation. The
states of Haryana and Punjab in India and at least seven nations in the world have
sanctioned maternity leave for six months or more12 (WABA). In Norway, the
Government provides leave for 42 weeks with full pay or 52 weeks at 80% pay. In
Sweden, the parental leave (shared by mothers and fathers) is for 18 months with 90% of
salary for the first 15 months19.
CONCLUSIONS
Recommended duration of exclusive breastfeeding and introduction of complementary
foods pose a challenge to the scientific community. Except in some rare cases,
breastfeeding is all that an infant needs till about six months of age. The earlier
recommendation of ‘exclusive breastfeeding for 4-6 months is based on the WHO
/UNICEF meeting on Infant and Young Child Feeding in 1979. This ‘4-6 months’ is
vague and that many women are likely to introduce foods at 2-3 months so that infants
will be eating well by fourth month.
New scientific evidence and the fact that many countries have adopted this policy and
recommendations of key international agencies favors a change in having a new
recommendation, ‘The infant should be exclusively breastfed from birth to about six
months, at which age complementary feeding should be provided along with continued
breastfeeding”
Complementary foods should be suited to the child’s ability and aptitude for flavor,
aroma, consistency, thickness and variety. In the initial period, complementation should
be addition to and not a replacement of breastfeed. Breastfeeding should be continued for
two years and beyond.
There is an urgent need to establish growth charts based on breastfed children since the
growth curves of breastfed infants differ from those currently used and since growth,
especially the weight, is the most commonly used parameter for ascertaining the
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adequacy of breastmilk. When the currently recommended charts are used, breastfed
children are likely to be considered as faltering and given complementary foods early.
The infants of working mothers are at a disadvantage. They are most likely to be fed nonhuman milk and complementary foods much earlier than recommended. It is necessary to
ensure that facilities for continuing exclusive breastfeeding are made available at the
work place and that the maternity leave is extended to cover the six-month period of
exclusive breastfeeding.
A review of the relevant literature published during the last 10 years and of the
statements/ recommendations/resolutions by various world bodies reveals that almost
since 19935b,38, the recommended duration of exclusive breastfeeding is “about six
months of age”. There seems to be some inertia in the propagation and acceptance of this
recommendation. Efforts must be made that all concerned have this information and feel
convinced about it so that exclusive breastfeeding for about six months is actively
promoted.
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Acknowledgements
The authors thank Dr.R.K. Anand, Dr Patrice Engle, Dr.Ted Griener, Dr N.B. Kumta,
Dr.K.P. Kushwaha, Dr.G.P. Mathur, Dr.Prakash S. Shrestha, Dr.Jagdish C. Sobti, and Dr
Arun Kumar Thakur for their useful comments on the earlier draft of this paper.
12