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Solids after 4 months often needed
- John A A Nichols (2 May 2008)
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Untitled
- KK Ong, Charlotte Wright, Rajalakshmi Lakshman, Pauline Emmett (10 July 2008)
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John A A Nichols, GP University of Surrey
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drjaan{at}ntlworld.com John A A Nichols
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There is a danger that the recommendation of exclusive breast-feeding up to six months will become an unworkable dogma. The WHO guidelines do point out the danger of growth faltering and iron and micronutrient deficiencies with exclusive breast-feeding in a minority of infants but the authors do not cover this adequately. Researchers have pointed out that breast milk may not always be sufficiently energy dense to sustain normal growth beyond three months. This could become critical at 58 kcal/100 ml, which is a commonly reported value for human breast milk (Morgan JB, Dickerson JWT. Nutrition in Early Life. Publisher: John Wiley & Sons, Chichester, England). The paper quoted by the authors to justify adoption of the WHO growth chart rather than the 1990 UK growth chart still shows growth faltering in 2-3% of infants at age 4 months (Wright C, Laksham R, Emmett P, Ong K. Implications of adopting the WHO 2006 child growth standard in the UK: two prospective cohort studies. Arch Dis Child; online 1 Oct 2007), however the authors concede that infants in their sample include a significant proportion (no figure given) who had supplemental feeds or solids both before and after 4 months. The authors are unable to quote data on the incidence of growth faltering with exclusive-breast feeding. This data does not exist? Most mothers will know when their 3-4 month infant is hungry despite adequate breast feeding. The next problem is to ensure that they are given the correct advice on starting supplementary solids (preferable to formula milk?) and this issue has not been addressed. |
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KK Ong, MRC Group Leader and paediatric Endocrinologist MRC Epidemiology Unit, Charlotte Wright, Rajalakshmi Lakshman, Pauline Emmett
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ken.ong{at}mrc-epid.cam.ac.uk KK Ong, et al.
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Dear Editor, We acknowledge Dr Nichols's point that the 2006 WHO charts still (and indeed fortunately) show that a small proportion of infants will demonstrate weight faltering and these infants may well need assessment for underlying pathology and/or nutritional support. Indeed the application of these WHO charts to UK practise is the subject of an ongoing DoH-funded RCPCH expert working group and implementation study, which we agree is a necessity before these charts can be safely launched in the UK, currently scheduled for March 2009 (http://www.rcpch.ac.uk/Research). We consider that the adequacy of exclusive breast-feeding is a different issue, which has been subject to much study and review (1) and also continuing debate (2). Yours sincerely C Wright, R Lakshman, P Emmett and K Ong 1) Kramer MS & Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2002;(1):CD003517). 2) Fewtrell et al. Optimal duration of exclusive breastfeeding: what is the evidence to support current recommendations? Am J Clin Nutr. 2007 Feb;85(2):635S-638S. |
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