It added that most early foods "are not nutrient dense and do not provide quantities of iron and zinc". Patti Rundall, of the campaigning group Baby Milk Action, said moving to weaning at four months would be "a regrettable and backward step that is out of step with current scientific thinking". She accused the paper's authors of taking funds from the babyfood industry. Fewtrell was unapologetic. Ideally, mothers would give their babies fresh food, including meat, for iron. Justine Roberts of Mumsnet said women needed clarity after at least three changes of policy in her own child-rearing years.
If that turns out not to be correct advice, we'd like to know as soon as possible. The Department of Health said it would review the research, adding: "Breast milk provides all the nutrients a baby needs up to six months of age and we recommend exclusive breastfeeding for this time.
Section on Breastfeeding. Breastfeeding and the Use of Human Milk external icon. DOI Accessed August 24, World Health Organization. WHO Breastfeeding website external icon. Centers for Disease Control and Prevention. Reasons for earlier than desired cessation of breastfeeding external icon. Sriraman NK, Kellams A. Although you can view the site well in any browser, printing from other browsers might not operate correctly. Click the Print button that is displayed on the web page not the Print command on the browser menu or toolbar.
This opens the browser print window. The window displays a preview of the document that will be printed. The preview might take a minute to display, depending on the document size. In the Printer box, select the desired printer. Click the Print button. If you are generating a PDF, click Save. You are prompted for the name and folder location to save the file. Thus a hour recall is done with mothers of all infants 0 - 5.
However, the resulting proportions represent a substantial exaggeration if assumed to represent how many babies are exclusively breastfed for the entire recommended six-month period. Several researchers have commented on this problem, as summarized by Agampodi et al. The implications of the use of different breastfeeding definitions in studying infant growth were explored by Piwoz et al.
In , WHO and others issued part 2 of a document on indicators for assessing infant and young child feeding which advised researchers to report on the proportion exclusively breastfeeding in smaller age groups if sample sizes allowed [ 11 ]. The goal of this paper is to explore methods of measuring exclusive breastfeeding and to argue that large-scale surveys should report both life-long data, that is, the proportion exclusively breastfeeding continuously from birth to any given age, and the point-in-time usually hour recall proportion at that same age or age group.
Exclusive breastfeeding, though likely practiced widely in the distant past, was no longer traditional by the time the feasibility of giving it a blanket recommendation was discovered and reported on [ 12 ] until that time, it was widely assumed that, at least in hot climates, breastfed babies needed additional water, so it was not possible to give a blanket recommendation to exclusively breastfeed, according to the modern WHO definition that excludes water.
Health workers, let alone mothers, had no conception of what it actually was and definitions were widely different even among researchers and breastfeeding specialists, certainly until a seminal paper on breastfeeding definitions was published [ 13 ].
Even now, varying definitions are commonly used, with the most common divergence from the WHO definition [ 6 ] being the inclusion of water [ 14 ].
Thus simply asking mothers how long they breastfed exclusively will rarely provide valid data. In one example [ 15 ], a definition was given only when the mother asked for it, likely resulting in data based on varying definitions. This problem can be eliminated by asking mothers either what they gave yesterday usually in the previous 24 hours; point-in-time or, to obtain life-long data, the age at which the infant first received each of a long list of locally fed liquids or solids in addition to breast milk followed by a question whether anything else was given and at what age it was introduced.
The age when the first supplement of any kind was given, including water, provides the duration of exclusive breastfeeding. The age at which milk or solid foods was first added then provides the duration of predominant breastfeeding. In most cultures, any life-long indicator will underestimate how much effective exclusive breastfeeding is going on, since a baby leaves the exclusive breastfeeding category as soon as anything else is introduced, even if this was a one-time phenomenon.
In reality, many babies may shift back and forth from being exclusively to predominantly to partially breastfed [ 16 ]. There will presumably not be many research objectives that would justify the effort required to record the cumulative number of days each baby has been fed each of these ways and I have not come across any. Certainly for large scale surveys, this would be too complex; for retrospective research the level of accuracy that could be obtained would be too low to achieve required levels of reliability and validity.
In such a setting, a life-long indicator will greatly underestimate exclusive breastfeeding for many purposes, indicating that most babies received none at all. The point-in-time method has an obvious advantage in avoiding the risk of recall error, but by definition sampling is limited to mothers with children under six months of age. Since so few babies are exactly six months old at the time of any survey, the hour recall method cannot be used to estimate how many babies are still exclusively breastfed at exactly six months of age.
Measuring the proportion of babies who are currently exclusively breastfeeding between five and six months of age would result in only a slight overestimate.
Some babies 5. Thus the proportion doing so for a full six months will be slightly less than what is estimated by looking at all babies 5. A survey of say children under five years of age a common age range covered in, for example, the DHS—Demographic and Health--surveys , would offer a sample size of only 50 - 60 infants five to six months of age, too small to provide an estimate stable enough to examine annual trends for example.
Some national surveys do overcome this either by having a much larger sample size or by oversampling infants and may thus sometimes arrive at a sample of 5. More common is still to combine all babies currently under six months of age sometimes estimates are based on all babies under four months of age which of course will yield an even higher percentage. The average age of the babies in a 0 - 6 months age group is clearly going to be about three months of age.
Thus variations in national durations of exclusive breastfeeding reported using this WHO indicator are heavily dependent on the extent of exclusive breastfeeding in the first 2 - 3 months. Nevertheless, the WHO indicator is useful and allows simple comparison among surveys not conducted on very large sample sizes; it is the misrepresentation and misreporting of this easily misunderstood indicator that is a major problem.
For cost reasons, most national surveys are cross-sectional and thus will conduct a hour recall only once. Even prospective research often uses repeat 24 hour recalls instead of asking whether any other food or fluid was introduced since the last questionnaire was administered. Some research uses a 7-day diary to obtain detailed data on the current feeding pattern [ 18 ] but clearly this is not feasible for most surveys.
While the duration of any breastfeeding tends to be recalled accurately even years later, recall of the ages when various other foods and fluids were introduced is much less accurate [ 19 ]. Bland et al. This problem is likely becoming worse in areas where exclusive breastfeeding is being widely promoted due to the social desirability bias.
In a recent Boston hospital sample followed prospectively for 3. Though only 0. Recall periods in large-scale retrospective surveys vary, and may do so even within the sample.
For example, in a recent national survey in the USA [ 22 ], the average recall period was about 7 months but could be up to 13 months. Recall errors will certainly be smaller the shorter the recall period is. Thus the optimal approach for obtaining life-long data on exclusive breastfeeding might be to interview all mothers with babies less than 7 or perhaps 9 months of age and ask them for each of a comprehensive list of locally used early supplements when it was first given to the baby.
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