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Policy and pragmatism in breast feeding
  1. JS Forsyth
  1. Correspondence to Professor James Stewart Forsyth, 1 Ellieslea Road, West Ferry, Dundee DD5 1JG, UK; stewartforsyth{at}

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The optimal duration of exclusive breast feeding is a subject of continuing debate. Most recently Fewtrell and colleagues1 have challenged the evidence underpinning the 2002 World Health Assembly endorsement of the recommendation that in both developing and developed countries exclusive breast feeding should be for a minimum of 6 months.2 They questioned whether there was sufficient evidence to support the change from 4 to 6 months in developed countries and they also suggested that the 6-month policy could be disadvantageous to some infants.

Questioning the validity of any aspect of breast feeding policy generates widespread media, professional and public interest and with the possibility of misinterpretation there is a potential risk that the key health message of breast milk being the nutrition of choice for newborn babies may be undermined. It is therefore important that the specific issue that has been raised is set within the wider context of breast feeding and health benefits. In relation to duration of exclusive breast feeding, there appears to be scientific and clinical consensus that in developing countries the optimal duration of exclusive breast feeding is 6 months. For developed countries there is a strong consensus of opinion, based on evidence from the UK and other developed countries, that there are important health benefits from exclusive breast feeding for a minimum of 4 months.3 However, there continues to be a division of opinion on the strength of evidence to support the World Health Organization (WHO) recommendation that in developed countries the minimum duration of exclusive breast feeding should be extended from 4 to 6 months.1

The WHO media response to the Fewtrell paper contained a reaffirmation of their recommendation that mothers worldwide should exclusively breast feed their infants for the first 6 months of life.4 Their evidence is underpinned by the systematic review by Kramer and Kakuma5 which reported that exclusive breast feeding for 6 months has several advantages over 3–4 months of exclusive breast feeding that is then followed by mixed breast feeding. These advantages were a lower risk of gastrointestinal infection for the infant, more rapid maternal weight loss after birth and delayed return of menstrual periods. In the Kramer and Kakuma review,5 the latter two outcomes were only reported in studies from two developing countries (Honduras and Senegal). The report of gastrointestinal illness in developed countries referred to an observational study undertaken in Belarus which noted that in the group of infants who were exclusively breast fed for 6 months, fewer infants had one or more episodes of gastrointestinal infection compared to infants who were exclusively breast fed for 4–6 months. However, there was no difference in the number of hospital admissions between the two groups.6 A follow-up of this cohort at 6.5 years found no significant health or cognitive differences between the two breast feeding groups except that the infants exclusively breast fed for 6 months had higher BMI and body fat measures.7

In relation to a minimum of 4 months of exclusive breast feeding, there is longstanding evidence from the UK and other developed countries of significant health benefit.8,,11 In the 1990s a series of papers from the Dundee Infant Feeding Study reported associations between exclusive breast feeding for 3–4 months and a reduction in infections during infancy, reduced childhood respiratory illness and lower blood pressure at the age of 7 years.9,,11 More recent studies have indicated that the impact of exclusive breast feeding on gastrointestinal infections is greatest during the first 4 months, with a smaller residual effect during the period of 4–6 months.12 13 The WHO intended the Global Strategy for Infant and Young Child Feeding to be a broad framework for international action and for each country to develop a comprehensive national strategy and action plan for infant and young child feeding.14 The two principles that guided the development of the global strategy were that it should be grounded on the best available scientific and epidemiological evidence, and it should be as participatory as possible. In relation to the former, the evidence on optimal duration of exclusive breast feeding was based on the Kramer and Kakuma systematic review.5 The participatory element included the draft strategy being considered at country consultations in Brazil, China, Philippines, Sri Lanka, Thailand, Zimbabwe and Scotland. A consistent message from practitioners in Scotland was that there was strong support for the aspiration of improving the initiation and duration of exclusive breast feeding, but with the Scottish breast feeding rates being so low, there was a real concern that a recommendation of 6 months of exclusive breast feeding may have a negative effect on parents and professionals. It was also felt that as Scottish research data indicated that 4 months of exclusive breast feeding offered significant health benefit to the Scottish population, it would be sensible to make that the initial target.

By subsequently endorsing a global, one size fits all, policy on duration of exclusive breast feeding,2 the WHO are asserting that extension of the minimum duration of exclusive breast feeding to 6 months will provide additional health benefit to all countries worldwide despite there being widespread variation in social, cultural, economic and educational factors. The response of member states to the 6-month minimum exclusive breast feeding recommendation has been varied, with some European countries and the USA not adopting the policy.1 As part of the deliberations within the UK, the government asked the Scientific Advisory Committee on Nutrition (SACN) to review the WHO policy and their response was that “there is sufficient scientific evidence that exclusive breast feeding for 6 months is nutritionally adequate”.15 They also comment that there should be some flexibility in the advice, but any complementary feeding should not be introduced before the end of 4 months (17 weeks). Interestingly, the SACN did not comment on the potential health gain from the additional 2 months of exclusive breast feeding, but they do state that while morbidity data can be used to compare the effects of early and late introduction of complementary foods, they would be extremely difficult, if not impossible, to obtain.

The UK government proceeded to translate the WHO recommendation into government policy in 200316 and, as highlighted by Fewtrell and colleagues, 8 years later there is still evidence that the policy lacks scientific and clinical consensus.1 Moreover, data from the Primary Care Trusts in England indicate that in the third quarter of 2009/2010 the prevalence of exclusive breast feeding at 6–8 weeks was 42% and ranged from 79% to 14%.17 The situation in Scotland is even more concerning, with the exclusive breast feeding rate at 6–8 weeks being 26.1% during 2009/2010; this has remained static since 2001/2002, the year that Scotland participated in the WHO consultation programme.18

To improve the current performance on exclusive breast feeding, a number of options need to be considered. First, it is important that policies on breast feeding within the UK are based on evidence that is robust and relevant and this should form the platform for improving breast feeding across the country. There is a need for transparency with the general public on the strength of available evidence and if the research evidence most relevant to the UK indicates that the first 4 months is the most crucial period for exclusive breast feeding to confer health gain, this should be reflected in the policy. Increasing the number of infants who are breast fed at 4 months will not only offer significant health benefits to these infants but will inevitably lead to more infants being exclusively breast fed for 6 months and beyond.

Second, although a recommendation of a minimum of 4 months of exclusive breast feeding would be considered a more consensual policy, implementation will need to be underpinned by a pragmatic approach to the critical stages of the breast feeding process – intention, initiation and maintenance. A declaration during the antenatal period of an intention to breast feed is a powerful predictor of successful maintenance of breast feeding. The reasons why women stop breast feeding have been extensively documented and they tend to relate to basic preventable health care issues such as sore nipples, concerns about adequacy of milk supply and perception that the infant is not satiated.19 20 Women who choose not to breast feed tend to be younger and from more deprived areas and for these women any period of exclusive breast feeding is a step in the right direction to break the cycle of health inequality. A focus on these aspects of basic care and practice may enable many more women to successfully breast feed.

Third, having repeatedly advised on the potential health gain that can be achieved by exclusive breast feeding, the government needs to demonstrate the same political imperative and financial commitment to implementation that has been given to other high profile health policies such as hospital waiting times. The government is currently urging a sharper focus on prevention21 and a strategic commitment to preventative care in breast feeding practice across the UK would be commensurate with the government strategy on preventative spending.

Finally, it must be recognised that even if the UK policy on breast feeding is evidence based and has scientific, clinical, public and government support, management systems need to be in place to ensure that the policy is effectively implemented. These include strong and visible national leadership that embodies research, clinical and user perspectives, agreed objectives and targets, effective local and national monitoring and a robust audit of performance. Moreover, more effective governance of infant feeding practice may not only address some of the long term disharmony that has been associated with infant feeding practices22 but may also instil a sense of direction, responsibility and partnership which are essential if the primary objective of improving the health of the population by increasing exclusive breast feeding, is to be met.



  • Competing interests The author has conducted cohort studies on health benefits of breast feeding and randomised controlled studies involving formula milks.

  • Provenance and peer review Not commissioned; externally peer reviewed.