Infant and young child feeding Model Chapter for textbooks for medical students and allied health professionals World Health Organization
Infant and young child feeding Model Chapter for textbooks for medical students and allied health professionals
甜 Contents Acknowledgments vi Abbreviations vi Introduction 1 Session 1 The importance of infant and young child feeding and recommended practices 3 Session 2 The physiological basis of breastfeeding 9 Session 3 Complementary feeding 19 Session 4 Management and support of infant feeding in maternity facilities 29 Session 5 Continuing support for infant and young child feeding 37 Session 6 Appropriate feeding in exceptionally difficult circumstances 57 Session 7 Management of breast conditions and other breastfeeding difficulties 65 Session 8 Mother's health 77 Session 9 Policy,health system and community actions 81 Annexes Annex 1 Acceptable medical reasons for use of breast-milk substitutes 89 Annex 2 Growth standards 92 Annex3 Growth velocity(weight-for-age)tables 95 Annex 4 Indicators for assessing infant and young child feeding practices 97 List of boxes,figures and tables Boxes Box1 Guiding principles for complementary feeding of the breastfed child 19 Box2 Responsive feeding 20 Box3 Five keys to safer food 21 Box4 Good complementary foods 23 Box5 The ten steps to successful breastfeeding 29 Box6 How to help a mother position and attach her baby 31
iii Acknowledgments vi Abbreviations vii Introduction 1 Session 1 The importance of infant and young child feeding and recommended practices 3 Session 2 The physiological basis of breastfeeding 9 Session 3 Complementary feeding 19 Session 4 Management and support of infant feeding in maternity facilities 29 Session 5 Continuing support for infant and young child feeding 37 Session 6 Appropriate feeding in exceptionally difficult circumstances 51 Session 7 Management of breast conditions and other breastfeeding difficulties 65 Session 8 Mother’s health 77 Session 9 Policy, health system and community actions 81 Annexes Annex 1 Acceptable medical reasons for use of breast-milk substitutes 89 Annex 2 Growth standards 92 Annex 3 Growth velocity (weight-for-age) tables 95 Annex 4 Indicators for assessing infant and young child feeding practices 97 List of boxes, figures and tables Boxes Box 1 Guiding principles for complementary feeding of the breastfed child 19 Box 2 Responsive feeding 20 Box 3 Five keys to safer food 21 Box 4 Good complementary foods 23 Box 5 The ten steps to successful breastfeeding 29 Box 6 How to help a mother position and attach her baby 31 Contents
INFANT AND YOUNG CHILD FEEDING-MODEL CHAPTER FOR TEXTBOOKS Box7 How to express breast milk by hand 32 Box8 How to cup feed a baby 34 Box9 Key points of contact to support optimal feeding practices 37 Box10 Communication and support skills 38 Box 11 Feeding History Job Aid,infants 0-6 months 42 B0X12 Feeding History Job Aid,children 6-23 months 43 Box 13 Breastfeed Observation Job Aid 44 Box 14 Supporting good feeding practices 48 Box 15 How to express breast milk directly into a baby's mouth 52 Box16 Definitions of Acceptable,Feasible,Affordable,Sustainable and Safe 60 Box 17 Replacement feeding 61 Box18 Lactational amenorrhoea method 79 Figures Figure 1 Major causes of death in neonates and children under five in the world,2004 3 Figure 2 Trends in exclusive breastfeeding rates(1996-2006) Figure3 Anatomy of the breast 11 Figure 4 Prolactin 11 Figure 5 Oxytocin 11 Figure 6 Good attachment-inside the infant's mouth 13 Figure 7 Poor attachment-inside the infant's mouth 13 Figure8 Good and poor attachment-external signs 14 Figure9 Baby well positioned at the breast 15 Figure 10 Energy required by age and the amount from breast milk 21 Figure 11 Gaps to be filled by complementary foods for a breastfed child 12-23 months 23 Figure 12 Back massage to stimulate the oxytocin reflex before expressing breast milk 32 Figure 13 Feeding a baby by cup 33 Figure 14 Measuring mid-upper arm circumference 40 Figure 15 Assessing and classifying infant and young child feeding 46 Figure 16 Useful positions to hold a LBW baby for breastfeeding 52 Figure 17 Cup feeding a low-birth-weight baby 53 Figure 18 Baby in Kangaroo mother care position 54 Figure 19 Using supplementary suckling to help a mother relactate 58
iv Infant and Young Child Feeding – Model Chapter for textbooks Box 7 How to express breast milk by hand 32 Box 8 How to cup feed a baby 34 Box 9 Key points of contact to support optimal feeding practices 37 Box 10 Communication and support skills 38 Box 11 Feeding History Job Aid, infants 0–6 months 42 Box 12 Feeding History Job Aid, children 6–23 months 43 Box 13 Breastfeed Observation Job Aid 44 Box 14 Supporting good feeding practices 48 Box 15 How to express breast milk directly into a baby’s mouth 52 Box 16 Definitions of Acceptable, Feasible, Affordable, Sustainable and Safe 60 Box 17 Replacement feeding 61 Box 18 Lactational amenorrhoea method 79 Figures Figure 1 Major causes of death in neonates and children under five in the world, 2004 3 Figure 2 Trends in exclusive breastfeeding rates (1996–2006) 4 Figure 3 Anatomy of the breast 11 Figure 4 Prolactin 11 Figure 5 Oxytocin 11 Figure 6 Good attachment – inside the infant’s mouth 13 Figure 7 Poor attachment – inside the infant’s mouth 13 Figure 8 Good and poor attachment – external signs 14 Figure 9 Baby well positioned at the breast 15 Figure 10 Energy required by age and the amount from breast milk 21 Figure 11 Gaps to be filled by complementary foods for a breastfed child 12–23 months 23 Figure 12 Back massage to stimulate the oxytocin reflex before expressing breast milk 32 Figure 13 Feeding a baby by cup 33 Figure 14 Measuring mid-upper arm circumference 40 Figure 15 Assessing and classifying infant and young child feeding 46 Figure 16 Useful positions to hold a LBW baby for breastfeeding 52 Figure 17 Cup feeding a low-birth-weight baby 53 Figure 18 Baby in Kangaroo mother care position 54 Figure 19 Using supplementary suckling to help a mother relactate 58
CONTENTS Figure 20 Preparing and using a syringe for treatment of inverted nipples 0 Figure 21 Dancer hand position 75 Figure 22 Elements of a comprehensive infant and young child feeding programme 82 Tables Table 1 Practical guidance on the quality,frequency and amount of food to offer children 6-23 months of age who are breastfed on demand 22 Table 2 High-dose universal distribution schedule for prevention of Vitamin A deficiency 25 Table3 Appropriate foods for complementary feeding 26 Table 4 Identifying growth problems from plotted points 41 Table 5 Food Intake Reference Tool,children 6-23 months Table 6 Feeding low-birth-weight babies 51 Table 7 Recommended fluid intake for LBW infants 53 Table 8 Recommended feed volumes for LBW infants 53 Table9 Reasons why a baby may not get enough breast milk 70 Table 10 Breastfeeding and mother's medication 78
v Figure 20 Preparing and using a syringe for treatment of inverted nipples 68 Figure 21 Dancer hand position 75 Figure 22 Elements of a comprehensive infant and young child feeding programme 82 Tables Table 1 Practical guidance on the quality, frequency and amount of food to offer children 6–23 months of age who are breastfed on demand 22 Table 2 High-dose universal distribution schedule for prevention of Vitamin A deficiency 25 Table 3 Appropriate foods for complementary feeding 26 Table 4 Identifying growth problems from plotted points 41 Table 5 Food Intake Reference Tool, children 6–23 months 47 Table 6 Feeding low-birth-weight babies 51 Table 7 Recommended fluid intake for LBW infants 53 Table 8 Recommended feed volumes for LBW infants 53 Table 9 Reasons why a baby may not get enough breast milk 70 Table 10 Breastfeeding and mother’s medication 78 Contents
vi Acknowledgments The development of this Model Chapter was initiated by the Department of Child and Adolescent Health and Development of the World Health Organization,as part of its efforts to promote the integration of evidence- based public health interventions in basic training of health professionals.The Model Chapter is designed for use in textbooks used by health sciences faculties,as a result of the positive experience with the Model Chapter on Integrated Management of Childhood Illness. The process of development of the Model Chapter on infant and young child feeding started in 2003.Drafts were presented in meetings with professors of health sciences schools in various regions and modifications made accordingly.There was an external review of the document in 2006,with the group of reviewers including Anto- nio da Cunha,Dai Yaohua,Nonhlanhla Dlamini,Hoang Trong Kim,Sandra Lang,Chessa Lutter,Nalini Singhal, Maryanne Stone-Jimenez and Elizabeth Rodgers.All of the reviewers have declared no conflict of interest.Even though the document was developed with inputs from many experts,some of them deserve special mention. Ann Brownlee edited an earlier version of the document,while Felicity Savage King wrote the final draft.Peggy Henderson conducted the editorial review.The three have declared no conflict of interest. Staff from the Departments of Child and Adolescent Health and Development and Nutrition for Health and Development were technically responsible and provided oversight to all aspects of the developmental work. While developing the Model Chapter,several updates of existing recommendations were conducted by WHO, and these were integrated into the Chapter.The updates include information on HIV and infant feeding(2007), management of uncomplicated severe acute malnutrition (2007),infant and young child feeding indicators (2008)and medical reasons for use of breast-milk substitutes(2008) The chapter is expected to be updated by the year 2013
vi Acknowledgments T he development of this Model Chapter was initiated by the Department of Child and Adolescent Health and Development of the World Health Organization, as part of its efforts to promote the integration of evidencebased public health interventions in basic training of health professionals. The Model Chapter is designed for use in textbooks used by health sciences faculties, as a result of the positive experience with the Model Chapter on Integrated Management of Childhood Illness. The process of development of the Model Chapter on infant and young child feeding started in 2003. Drafts were presented in meetings with professors of health sciences schools in various regions and modifications made accordingly. There was an external review of the document in 2006, with the group of reviewers including Antonio da Cunha, Dai Yaohua, Nonhlanhla Dlamini, Hoang Trong Kim, Sandra Lang, Chessa Lutter, Nalini Singhal, Maryanne Stone-Jimenez and Elizabeth Rodgers. All of the reviewers have declared no conflict of interest. Even though the document was developed with inputs from many experts, some of them deserve special mention. Ann Brownlee edited an earlier version of the document, while Felicity Savage King wrote the final draft. Peggy Henderson conducted the editorial review. The three have declared no conflict of interest. Staff from the Departments of Child and Adolescent Health and Development and Nutrition for Health and Development were technically responsible and provided oversight to all aspects of the developmental work. While developing the Model Chapter, several updates of existing recommendations were conducted by WHO, and these were integrated into the Chapter. The updates include information on HIV and infant feeding (2007), management of uncomplicated severe acute malnutrition (2007), infant and young child feeding indicators (2008) and medical reasons for use of breast-milk substitutes (2008) The chapter is expected to be updated by the year 2013
vii Abbreviations ARA Arachidonic acid ARVs Anti-retroviral drugs BFHI Baby-friendly Hospital Initiative BMS Breast-milk substitute cm centimetre Code International Code of Marketing of Breast-milk Substitutes(including subsequent relevant World Health Assembly resolutions) CRC Convention on the Rights of the Child DHA Docosahexaenoic acid EBM Expressed breast milk ENA Essential Nutrition Actions FIL Feedback inhibitor of lactation gram GnRH Gonadotrophic releasing hormone ILO International Labour Organization IMCI Integrated management of childhood illness IUGR Intrauterine growth retardation Kcal kilocalorie KMC Kangaroo mother care LBW Low birth weight ml millilitre MTCT Mother-to-child transmission of HIV MUAC Middle upper-arm circumference NGO Non-governmental organization RUTF Ready-to-use therapeutic food SGA Small for gestational age slgA secretory immunoglobulin A VBLW Very low birth weight WHA World Health Assembly
vii Abbreviations ARA Arachidonic acid ARVs Anti-retroviral drugs BFHI Baby-friendly Hospital Initiative BMS Breast-milk substitute cm centimetre Code International Code of Marketing of Breast-milk Substitutes (including subsequent relevant World Health Assembly resolutions) CRC Convention on the Rights of the Child DHA Docosahexaenoic acid EBM Expressed breast milk ENA Essential Nutrition Actions FIL Feedback inhibitor of lactation g gram GnRH Gonadotrophic releasing hormone ILO International Labour Organization IMCI Integrated management of childhood illness IUGR Intrauterine growth retardation Kcal kilocalorie KMC Kangaroo mother care LBW Low birth weight ml millilitre MTCT Mother-to-child transmission of HIV MUAC Middle upper-arm circumference NGO Non-governmental organization RUTF Ready-to-use therapeutic food SGA Small for gestational age slgA secretory immunoglobulin A VBLW Very low birth weight WHA World Health Assembly
1 Introduction a the mere there are feeding problems,and they may overtly or covertly promote breast-milk substitutes. improve child health.In 2006 an estimated 9.5 mil- This Model Chapter brings together essential knowl- lion children died before their fifth birthday,and two thirds of these deaths occurred in the first year of life. edge about infant and young child feeding that health Under-nutritionisassociated withatleast 35%ofchild professionals should acquire as part of their basic education.It focuses on nutritional needs and feed- deaths.It is also a major disabler preventing children ing practices in children less than 2 years of age-the who survive from reaching their full developmental most critical period for child nutrition after which potential.Around 32%of children less than 5 years of age in developing countries are stunted and 10% sub-optimal growth is hard to reverse.The Chapter does not impart skills,although it includes descrip- are wasted.It is estimated that sub-optimal breast- tions of essential skills that every health professional feeding,especially non-exclusive breastfeeding in the should master,such as positioning and attachment first 6 months of life,results in 1.4 million deaths and for breastfeeding. 10%of the disease burden in children younger than 5 years. The Model Chapter is organized in nine sessions according to topic areas,with scientific references at To improve this situation,mothers and families need the end of each section.These references include arti- support to initiate and sustain appropriate infant and cles or WHO documents that provide evidence and young child feeding practices.Health care profession- als can play a critical role in providing that support, further information about specific points. through influencing decisions about feeding practices Useful resource materials are listed on the inside of among mothers and families.Therefore,it is critical the back cover.Training institutions may find it use- for health professionals to have basic knowledge and ful to have these resources available for students skills to give appropriate advice,counsel and help The Chapter is accompanied by a CD-ROM with ref- solve feeding difficulties,and know when and where erence materials.It includes an annotated listing of to refer a mother who experiences more complex references presented in the Model Chapter,Power- feeding problems. Point slides to support technical seminars on infant Child health in general,and infant and young child and young child feeding,and the document Effective feeding more specifically,is often not well addressed teaching:a guide for educating healthcare profession- in the basic training of doctors,nurses and other als that can be used to identify effective methods allied health professionals.Because oflack ofadequate and approaches to introduce the content.Proposed knowledge and skills,health professionals are often learning objectives and core competencies for medi- barriers to improved feeding practices.For example, cal students and allied health professionals in the area they may not know how to assist a mother to initiate of infant and young child feeding are also part of the and sustain exclusive breastfeeding,they may recom- CD-ROM. mend too-early introduction of supplements when
1 Introduction Optimal infant and young child feeding practices rank among the most effective interventions to improve child health. In 2006 an estimated 9.5 million children died before their fifth birthday, and two thirds of these deaths occurred in the first year of life. Under-nutrition is associated with at least 35% of child deaths. It is also a major disabler preventing children who survive from reaching their full developmental potential. Around 32% of children less than 5 years of age in developing countries are stunted and 10% are wasted. It is estimated that sub-optimal breastfeeding, especially non-exclusive breastfeeding in the first 6 months of life, results in 1.4 million deaths and 10% of the disease burden in children younger than 5 years. To improve this situation, mothers and families need support to initiate and sustain appropriate infant and young child feeding practices. Health care professionals can play a critical role in providing that support, through influencing decisions about feeding practices among mothers and families. Therefore, it is critical for health professionals to have basic knowledge and skills to give appropriate advice, counsel and help solve feeding difficulties, and know when and where to refer a mother who experiences more complex feeding problems. Child health in general, and infant and young child feeding more specifically, is often not well addressed in the basic training of doctors, nurses and other allied health professionals. Because of lack of adequate knowledge and skills, health professionals are often barriers to improved feeding practices. For example, they may not know how to assist a mother to initiate and sustain exclusive breastfeeding, they may recommend too-early introduction of supplements when there are feeding problems, and they may overtly or covertly promote breast-milk substitutes. This Model Chapter brings together essential knowledge about infant and young child feeding that health professionals should acquire as part of their basic education. It focuses on nutritional needs and feeding practices in children less than 2 years of age – the most critical period for child nutrition after which sub-optimal growth is hard to reverse. The Chapter does not impart skills, although it includes descriptions of essential skills that every health professional should master, such as positioning and attachment for breastfeeding. The Model Chapter is organized in nine sessions according to topic areas, with scientific references at the end of each section. These references include articles or WHO documents that provide evidence and further information about specific points. Useful resource materials are listed on the inside of the back cover. Training institutions may find it useful to have these resources available for students. The Chapter is accompanied by a CD-ROM with reference materials. It includes an annotated listing of references presented in the Model Chapter, PowerPoint slides to support technical seminars on infant and young child feeding, and the document Effective teaching: a guide for educating healthcare professionals that can be used to identify effective methods and approaches to introduce the content. Proposed learning objectives and core competencies for medical students and allied health professionals in the area of infant and young child feeding are also part of the CD-ROM
The importance of infant and young child feeding and recommended practices 1.1 Growth.health and FIGURE 1 development Major causes of death in neonates and children under five in the world,2004 Adequate nutrition during infan- Deaths among children under five Neonatal deaths cy and early childhood is essen- Noncommunicablediseases tial to ensure the growth,health, (postnecnatal)4% and development of children to Other 1.3% their full potential.Poor nutrition HIV/AIDS 2%- Congenital anomalies 6.8% increases the risk of illness,and is Neonatal tetanus 3.4% Measles 4% Diarhoeal diseases 2.6% responsible,directly or indirectly, Malaria7% for one third of the estimated 6 Neonatal infections 26% 9.5 million deaths that occurred in 2006 in children less than 5 years of age(1,2)(Figure 1).Inap- Prematurity and Acute respiratory low birth weight 31% propriate nutrition can also lead 35%of under-five deaths are due to the presence of undernutrition to childhood obesity which is an increasing public health problem Sources:World Health Organization.The globalburden ofdisease:2004 update.Geneva,World Health Organization, in many countries. 2008;Black Ret al.Maternal and child undernutrition:global and regional exposures and health consequences. Lancet,,2008,371243-260. Early nutritional deficits are also linked to long-term impairment in growth and health. 1.2 The Global Strategy for infant and Malnutrition during the first 2 years of life causes young child feeding stunting,leading to the adult being several centime- In 2002,the World Health Assembly and UNICEF tres shorter than his or her potential height(3).There is evidence that adults who were malnourished in ear- adopted the Global Strategy for infant and young child ly childhood have impaired intellectual performance feeding(10).The strategy was developed to revitalise (4).They may also have reduced capacity for physical world attention to the impact that feeding practices have on the nutritional status,growth and devel- work(5,6).If women were malnourished as children, their reproductive capacity is affected,their infants opment,health,and survival of infants and young children(see also Session9).This Model Chapter sum- may have lower birth weight,and they have more complicated deliveries(7).When many children in a marizes essential knowledge that every health profes- population are malnourished,it has implications for sional should have in order to carry out the crucial national development.The overall functional conse- role of protecting,promoting and supporting appro- quences of malnutrition are thus immense. priate infant and young child feeding in accordance with the principles of the Global Strategy. The first two years of life provide a critical window of opportunity for ensuring children's appropri- 1.3 Recommended infant and young child feeding ate growth and development through optimal feed- practices ing(8).Based on evidence of the effectiveness of WHO and UNICEF's global recommendations for interventions,achievement of universal coverage of optimal infant feeding as set out in the Global Strat- optimal breastfeeding could prevent 13%of deaths egy are: occurring in children less than 5 years of age globally, while appropriate complementary feeding practices exclusive breastfeeding for 6 months (180 days) would result in an additional 6%reduction in under- (11): five mortality (9)
The importance of infant and young child feeding and recommended practices 1.1 Growth, health and development Adequate nutrition during infancy and early childhood is essential to ensure the growth, health, and development of children to their full potential. Poor nutrition increases the risk of illness, and is responsible, directly or indirectly, for one third of the estimated 9.5 million deaths that occurred in 2006 in children less than 5 years of age (1,2) (Figure 1). Inappropriate nutrition can also lead to childhood obesity which is an increasing public health problem in many countries. Early nutritional deficits are also linked to long-term impairment in growth and health. Malnutrition during the first 2 years of life causes stunting, leading to the adult being several centimetres shorter than his or her potential height (3). There is evidence that adults who were malnourished in early childhood have impaired intellectual performance (4). They may also have reduced capacity for physical work (5,6). If women were malnourished as children, their reproductive capacity is affected, their infants may have lower birth weight, and they have more complicated deliveries (7). When many children in a population are malnourished, it has implications for national development. The overall functional consequences of malnutrition are thus immense. The first two years of life provide a critical window of opportunity for ensuring children’s appropriate growth and development through optimal feeding (8). Based on evidence of the effectiveness of interventions, achievement of universal coverage of optimal breastfeeding could prevent 13% of deaths occurring in children less than 5 years of age globally, while appropriate complementary feeding practices would result in an additional 6% reduction in underfive mortality (9). 1.2 The Global Strategy for infant and young child feeding In 2002, the World Health Assembly and UNICEF adopted the Global Strategy for infant and young child feeding (10). The strategy was developed to revitalise world attention to the impact that feeding practices have on the nutritional status, growth and development, health, and survival of infants and young children (see also Session 9). This Model Chapter summarizes essential knowledge that every health professional should have in order to carry out the crucial role of protecting, promoting and supporting appropriate infant and young child feeding in accordance with the principles of the Global Strategy. 1.3 Recommended infant and young child feeding practices WHO and UNICEF’s global recommendations for optimal infant feeding as set out in the Global Strategy are: K exclusive breastfeeding for 6 months (180 days) (11); Sources: World Health Organization. The global burden of disease: 2004 update. Geneva, World Health Organization, 2008; Black R et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet, 2008, 371:243–260. Figure 1 Major causes of death in neonates and children under five in the world, 2004 Noncommunicable diseases (postneonatal) 4% Injuries (postneonatal) 4% Neonatal deaths 36% Other infectious and parasitic diseases 9% HIV/AIDS 2% Measles 4% Malaria 7% Diarrhoeal diseases (postneonatal) 16% Acute respiratory infections (postneonatal) 17% Other 1.3% Congenital anomalies 6.8% Neonatal tetanus 3.4% Diarrhoeal diseases 2.6% Other non-infectious perinatal causes 5.7% Neonatal infections 26% Birth asphyxia and birth trauma 23% Prematurity and low birth weight 31% Deaths among children under five Neonatal deaths 35% of under-five deaths are due to the presence of undernutrition Session 1
4 INFANT AND YOUNG CHILD FEEDING-MODEL CHAPTER FOR TEXTBOOKS FIGURE 2 Trends in exclusive breastfeeding rates(1996-2006) 50 20und1996 eround 2006 (EE还 Middle East/ Sub-Saharan East Asia/Pacific South Asi地 Developing countrie座 North Africa Africa (exduding China) (exduding Chinal Source:UNICEF.Progress for children:a world fit for children.Statistical Review,Number 6.New York,UNICEF,2007 nutritionally adequate and safe complementary foods are often introduced too early or too late and are feeding starting from the age of 6 months with con- often nutritionally inadequate and unsafe. tinued breastfeeding up to 2 years of age or beyond. Data from 64 countries covering 69%of births in Exclusive breastfeeding means that an infant receives the developing world suggest that there have been only breast milk from his or her mother or a wet improvements in this situation.Between 1996 and nurse,or expressed breast milk,and no other liquids 2006 the rate of exclusive breastfeeding for the first or solids,not even water,with the exception of oral 6 months of life increased from 33%to 37%.Sig- rehydration solution,drops or syrups consisting of nificant increases were made in sub-Saharan Africa, vitamins,minerals supplements or medicines(12). where rates increased from 22%to 30%;and Europe, Complementary feeding is defined as the process start- with rates increasing from 10%to 19%(Figure 2).In Latin America and the Caribbean,excluding Bra- ing when breast milk is no longer sufficient to meet the nutritional requirements of infants,and therefore oth- zil and Mexico,the percentage of infants exclusively er foods and liquids are needed,along with breast milk. breastfed increased from 30%in around 1996 to 45% The target range for complementary feeding is gener- in around 2006(15). ally taken to be 6 to 23 months of age,even though breastfeeding may continue beyond two years(13). 1.5 Evidence for recommended feeding practices These recommendations may be adapted according Breastfeeding to the needs of infants and young children in excep- Breastfeeding confers short-term and long-term tionally difficult circumstances,such as pre-term benefits on both child and mother (16),including or low-birth-weight infants,severely malnourished helping to protect children against a variety of acute children,and in emergency situations(see Session 6). and chronic disorders.The long-term disadvantages Specific recommendations apply to infants born to of not breastfeeding are increasingly recognized as HIV-infected mothers important(1718). Reviews of studies from developing countries show 1.4 Current status of infant and young child that infants who are not breastfed are 6(19)to 10 feeding globally times(20)more likely to die in the first months of life Poor breastfeeding and complementary feeding prac- than infants who are breastfed.Diarrhoea (21)and tices are widespread.Worldwide,it is estimated that pneumonia(22)are more common and more severe only 34.8%of infants are exclusively breastfed for the in children who are artificially fed,and are responsi- first 6 months oflife,the majority receiving some other ble for many of these deaths.Diarrhoeal illness is also food or fluid in the early months(14).Complementary more common in artificially-fed infants even in situ- ations with adequate hygiene,as in Belarus(23)and When describing age ranges,a child 6-23 months has complet- Scotland(24).Other acute infections,including otitis ed 6 months but has an age less than 2 years. media (25),Haemophilus influenzae meningitis (26)
4 Infant and Young Child Feeding – Model Chapter for textbooks K nutritionally adequate and safe complementary feeding starting from the age of 6 months with continued breastfeeding up to 2 years of age or beyond. Exclusive breastfeeding means that an infant receives only breast milk from his or her mother or a wet nurse, or expressed breast milk, and no other liquids or solids, not even water, with the exception of oral rehydration solution, drops or syrups consisting of vitamins, minerals supplements or medicines (12). Complementary feeding is defined as the process starting when breast milk is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk. The target range for complementary feeding is generally taken to be 6 to 23 months of age,1 even though breastfeeding may continue beyond two years (13). These recommendations may be adapted according to the needs of infants and young children in exceptionally difficult circumstances, such as pre-term or low-birth-weight infants, severely malnourished children, and in emergency situations (see Session 6). Specific recommendations apply to infants born to HIV-infected mothers. 1.4 Current status of infant and young child feeding globally Poor breastfeeding and complementary feeding practices are widespread. Worldwide, it is estimated that only 34.8% of infants are exclusively breastfed for the first 6 months of life, the majority receiving some other food or fluid in the early months (14). Complementary foods are often introduced too early or too late and are often nutritionally inadequate and unsafe. Data from 64 countries covering 69% of births in the developing world suggest that there have been improvements in this situation. Between 1996 and 2006 the rate of exclusive breastfeeding for the first 6 months of life increased from 33% to 37%. Significant increases were made in sub-Saharan Africa, where rates increased from 22% to 30%; and Europe, with rates increasing from 10% to 19% (Figure 2). In Latin America and the Caribbean, excluding Brazil and Mexico, the percentage of infants exclusively breastfed increased from 30% in around 1996 to 45% in around 2006 (15). 1.5 Evidence for recommended feeding practices Breastfeeding Breastfeeding confers short-term and long-term benefits on both child and mother (16), including helping to protect children against a variety of acute and chronic disorders. The long-term disadvantages of not breastfeeding are increasingly recognized as important (17,18). Reviews of studies from developing countries show that infants who are not breastfed are 6 (19) to 10 times (20) more likely to die in the first months of life than infants who are breastfed. Diarrhoea (21) and pneumonia (22) are more common and more severe in children who are artificially fed, and are responsible for many of these deaths. Diarrhoeal illness is also more common in artificially-fed infants even in situations with adequate hygiene, as in Belarus (23) and Scotland (24). Other acute infections, including otitis media (25), Haemophilus influenzae meningitis (26), 1 When describing age ranges, a child 6–23 months has completed 6 months but has an age less than 2 years. Source: UNICEF. Progress for children: a world fit for children. Statistical Review, Number 6. New York, UNICEF, 2007. Figure 2 Trends in exclusive breastfeeding rates (1996–2006) 0 10 20 30 40 50 0 10 20 30 40 50 Percentage of infants exclusively breastfed for the first six months of life CEE/CIS Middle East/ North Africa Sub-Saharan Africa East Asia/Pacific (excluding China) South Asia Developing countries (excluding China) around 1996 around 2006 10 19 30 26 22 30 27 32 44 45 33 37
1.THE IMPORTANCE OF INFANT AND YOUNG CHILD FEEDING AND RECOMMENDED PRACTICES and urinary tract infection(27),are less common and were exclusively instead of partially breastfed for the less severe in breastfed infants first 4 months of life (48).Exclusive breastfeeding for 6 Artificially-fed children have an increased risk oflong- months has been found to reduce the risk of diarrhoea term diseases with an immunological basis,including (49)and respiratory illness(50)compared with exclu- asthma and other atopic conditions (28,29),type 1 sive breastfeeding for 3 and 4 months respectively. diabetes(30),celiac disease(31),ulcerative colitis and If the breastfeeding technique is satisfactory,exclu- Crohn disease(32).Artificial feeding is also associ- sive breastfeeding for the first 6 months of life meets ated with a greater risk of childhood leukaemia(33). the energy and nutrient needs of the vast majority of Several studies suggest that obesity in later childhood infants (51).No other foods or fluids are necessary. and adolescence is less common among breastfed chil- Several studies have shown that healthy infants do dren,and that there is a dose response effect,with a not need additional water during the first 6 months longer duration of breastfeeding associated with a low- if they are exclusively breastfed,even in a hot climate. er risk (34,35).The effect may be less clear in popula- Breast milk itself is 88%water,and is enough to sat- tions where some children are undernourished(36).A isfy a baby's thirst (52).Extra fluids displace breast growing body of evidence links artificial feeding with milk,and do not increase overall intake (53).How- risks to cardiovascular health,including increased ever,water and teas are commonly given to infants, blood pressure (37),altered blood cholesterol levels often starting in the first week of life.This practice (38)and atherosclerosis in later adulthood (39). has been associated with a two-fold increased risk of diarrhoea (54). Regarding intelligence,a meta-analysis of 20 studies (40)showed scores of cognitive function on average For the mother,exclusive breastfeeding can delay 3.2 points higher among children who were breastfed the return of fertility (55),and accelerate recovery of compared with those who were formula fed.The dif- pre-pregnancy weight(56).Mothers who breastfeed exclusively and frequently have less than a 2%risk of ference was greater (by 5.18 points)among those chil- dren who were born with low birth weight.Increased becoming pregnant in the first 6 months postpartum, duration of breastfeeding has been associated with provided that they still have amenorrhoea(see Session greater intelligence in late childhood(41)and adult- 8.4.1) hood (42),which may affect the individual's ability to contribute to society. Complementary feeding from 6 months From the age of 6 months,an infant's need for energy For the mother,breastfeeding also has both short-and and nutrients starts to exceed what is provided by long-term benefits.The risk of postpartum haemor- breast milk,and complementary feeding becomes rhage may be reduced by breastfeeding immediately necessary to fill the energy and nutrient gap(57).If after delivery (43),and there is increasing evidence complementary foods are not introduced at this age that the risk of breast (44)and ovarian (45)cancer is or if they are given inappropriately,an infant's growth less among women who breastfed. may falter.In many countries,the period of comple- mentary feeding from 6-23 months is the time of Exclusive breastfeeding for 6 months peak incidence of growth faltering,micronutrient The advantages of exclusive breastfeeding compared deficiencies and infectious illnesses(58) to partial breastfeeding were recognised in 1984, when a review of available studies found that the risk Even after complementary foods have been intro- of death from diarrhoea of partially breastfed infants duced,breastfeeding remains a critical source of 0-6 months of age was 8.6 times the risk for exclu- nutrients for the young infant and child.It provides sively breastfed children.For those who received no about one half of an infant's energy needs up to the breast milk the risk was 25 times that of those who age of one year,and up to one third during the second were exclusively breastfed (46).A study in Brazil in year of life.Breast milk continues to supply higher 1987 found that compared with exclusive breastfeed- quality nutrients than complementary foods,and also ing,partial breastfeeding was associated with 4.2 protective factors.It is therefore recommended that times the risk of death,while no breastfeeding had breastfeeding on demand continues with adequate 14.2 times the risk(47).More recently,a study in Dha- complementary feeding up to 2 years or beyond (13). ka,Bangladesh found that deaths from diarrhoea and Complementary foods need to be nutritionally- pneumonia could be reduced by one third if infants adequate,safe,and appropriately fed in order to meet
1. The importance of infant and young child feeding and recommended practices 5 and urinary tract infection (27), are less common and less severe in breastfed infants. Artificially-fed children have an increased risk of longterm diseases with an immunological basis, including asthma and other atopic conditions (28,29), type 1 diabetes (30), celiac disease (31), ulcerative colitis and Crohn disease (32). Artificial feeding is also associated with a greater risk of childhood leukaemia (33). Several studies suggest that obesity in later childhood and adolescence is less common among breastfed children, and that there is a dose response effect, with a longer duration of breastfeeding associated with a lower risk (34,35). The effect may be less clear in populations where some children are undernourished (36). A growing body of evidence links artificial feeding with risks to cardiovascular health, including increased blood pressure (37), altered blood cholesterol levels (38) and atherosclerosis in later adulthood (39). Regarding intelligence, a meta-analysis of 20 studies (40) showed scores of cognitive function on average 3.2 points higher among children who were breastfed compared with those who were formula fed. The difference was greater (by 5.18 points) among those children who were born with low birth weight. Increased duration of breastfeeding has been associated with greater intelligence in late childhood (41) and adulthood (42), which may affect the individual’s ability to contribute to society. For the mother, breastfeeding also has both short- and long-term benefits. The risk of postpartum haemorrhage may be reduced by breastfeeding immediately after delivery (43), and there is increasing evidence that the risk of breast (44) and ovarian (45) cancer is less among women who breastfed. Exclusive breastfeeding for 6 months The advantages of exclusive breastfeeding compared to partial breastfeeding were recognised in 1984, when a review of available studies found that the risk of death from diarrhoea of partially breastfed infants 0–6 months of age was 8.6 times the risk for exclusively breastfed children. For those who received no breast milk the risk was 25 times that of those who were exclusively breastfed (46). A study in Brazil in 1987 found that compared with exclusive breastfeeding, partial breastfeeding was associated with 4.2 times the risk of death, while no breastfeeding had 14.2 times the risk (47). More recently, a study in Dhaka, Bangladesh found that deaths from diarrhoea and pneumonia could be reduced by one third if infants were exclusively instead of partially breastfed for the first 4 months of life (48). Exclusive breastfeeding for 6 months has been found to reduce the risk of diarrhoea (49) and respiratory illness (50) compared with exclusive breastfeeding for 3 and 4 months respectively. If the breastfeeding technique is satisfactory, exclusive breastfeeding for the first 6 months of life meets the energy and nutrient needs of the vast majority of infants (51). No other foods or fluids are necessary. Several studies have shown that healthy infants do not need additional water during the first 6 months if they are exclusively breastfed, even in a hot climate. Breast milk itself is 88% water, and is enough to satisfy a baby’s thirst (52). Extra fluids displace breast milk, and do not increase overall intake (53). However, water and teas are commonly given to infants, often starting in the first week of life. This practice has been associated with a two-fold increased risk of diarrhoea (54). For the mother, exclusive breastfeeding can delay the return of fertility (55), and accelerate recovery of pre-pregnancy weight (56). Mothers who breastfeed exclusively and frequently have less than a 2% risk of becoming pregnant in the first 6 months postpartum, provided that they still have amenorrhoea (see Session 8.4.1). Complementary feeding from 6 months From the age of 6 months, an infant’s need for energy and nutrients starts to exceed what is provided by breast milk, and complementary feeding becomes necessary to fill the energy and nutrient gap (57). If complementary foods are not introduced at this age or if they are given inappropriately, an infant’s growth may falter. In many countries, the period of complementary feeding from 6–23 months is the time of peak incidence of growth faltering, micronutrient deficiencies and infectious illnesses (58). Even after complementary foods have been introduced, breastfeeding remains a critical source of nutrients for the young infant and child. It provides about one half of an infant’s energy needs up to the age of one year, and up to one third during the second year of life. Breast milk continues to supply higher quality nutrients than complementary foods, and also protective factors. It is therefore recommended that breastfeeding on demand continues with adequate complementary feeding up to 2 years or beyond (13). Complementary foods need to be nutritionallyadequate, safe, and appropriately fed in order to meet