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 meet1. 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 long￾term 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 associ￾ated with a greater risk of childhood leukaemia (33). Several studies suggest that obesity in later childhood and adolescence is less common among breastfed chil￾dren, and that there is a dose response effect, with a longer duration of breastfeeding associated with a low￾er risk (34,35). The effect may be less clear in popula￾tions 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 dif￾ference was greater (by 5.18 points) among those chil￾dren who were born with low birth weight. Increased duration of breastfeeding has been associated with greater intelligence in late childhood (41) and adult￾hood (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 haemor￾rhage 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 exclu￾sively 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 breastfeed￾ing, 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 Dha￾ka, 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 exclu￾sive breastfeeding for 3 and 4 months respectively. If the breastfeeding technique is satisfactory, exclu￾sive 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 sat￾isfy a baby’s thirst (52). Extra fluids displace breast milk, and do not increase overall intake (53). How￾ever, 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 comple￾mentary 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 intro￾duced, 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 nutritionally￾adequate, safe, and appropriately fed in order to meet