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Breast is best? The debate continues ...

Polly Moffat
Supervising Editor
Nursing in Practice

Infant nutrition has long been a contentious issue. This article focuses on the current UK guidance, what we know about breastfeeding and whether or not the messages are getting through to professionals and parents

Astorm was ignited in the press recently over an article published by a team from University College London's (UCL) Institute of Child Health, which claimed that if babies only receive breast milk in the first six months they may be more prone to allergies and could suffer iron deficiency.

In 2001, the World Health Organization (WHO) announced a global recommendation that the best option for babies and mothers in terms of nutrition and health is breast milk alone for the first six months of life, with solid food being introduced subsequently. This was then adopted as policy by the UK government and is the current advice given to parents by health professionals.

In the guidance, the WHO recommends:

  • Initiation of breastfeeding within the first hour of life.
  • Exclusive breastfeeding - that is the infant only receives breast milk without any additional food or drink, not even water.
  • Breastfeeding on demand - that is as often as the child wants, day and night.
  • No use of bottles, teats or pacifiers [dummies].

Media frenzy
An article published in the British Medical Journal (BMJ) in January 2011 by a team of researchers from UCL appeared to refute the claim that six months of exclusive breast milk was sufficient for healthy development. In the paper, the authors suggest that solid foods should be introduced at an earlier stage to ensure the right amount of nutrients are present in the diet.

When it was published by the BMJ, the story was picked up by the national and international press, and the resulting media frenzy added little to the debate except confusion about the messages that are given to prospective parents about the best method for feeding infants.

Pro-breastfeeding groups and organisations, such as the Royal College of Midwives (RCM) and Scientific Advisory Committee on Nutrition (SACN), contributed to the argument with their own views about the current recommendations from the WHO and why they should be adhered to. It is known that the UK has one of the lowest breastfeeding rates in Europe, but the reason for this is less clear. According to UNICEF, who have set targets for breastfeeding as part of their Baby Friendly initiative in maternity settings throughout the country, only 35% of UK babies are being exclusively breastfed at one week, with 21% at six weeks, 7% at four months and 3% at five months.

The authors of the BMJ article, including Mary Fewtrell, Reader in Childhood Nutrition and Honorary Consultant Paediatrician, and Alan Lucas, Director of the Institute of Child Health at UCL, called for the policy to be re-examined in the UK, arguing that the need for solid foods varies from infant to infant and that breast milk alone may not be enough to give some children the best start in life. This perhaps controversial view is tempered by the authors themselves, who were surprised by the vociferous response to the article, and the idea that it was promoting formula rather than breast milk as the best form of nutrition for infants.

Dr Fewtrell said: “I'm not saying we should be dictating policy - my personal view is that we should say mothers should breastfeed for four months and when they feel it is right, introduce solids between four and six months. Babies grow at different rates and the idea that six months should be a benchmark is bizarre. My concern is that [the policy] is out of keeping with what mothers think they should be doing - a minority of mothers actually do it.”

An emotive issue
Why is breastfeeding is such an emotive issue within the UK? Discussion about the article raises the question of attitudes in Britain towards breastfeeding and the current ‘formula culture', which frowns upon breastfeeding as a socially acceptable way for women to feed their baby, particularly in public places.
Dr Fewtrell says, “Most of my colleagues internationally wonder why we are obsessed with the issue. We seem to have this religious fervour about the whole thing, and I think we should be talking about the science. We went out of our way to say that we support breastfeeding, but we were talking about introducing solids … and we felt there should have been more of a review of what was needed for the UK.”

The BMJ article claims that there is new evidence to suggest prolonged breastfeeding without introducing solid foods correlates with increased cases of allergy in developed countries. This goes against the common assumption that exclusive breast milk can help to protect against allergy.
In response, critics of the article state that the authors are incorrect in citing evidence regarding the link to allergy, and that this only goes to undermine the campaign in favour of breastfeeding as the most natural way of providing nutrition for infants. Mary Renfrew, founder and Director of the Mother and Infant Research Unit at the University of York, feels that the issue has been misunderstood by many. She says, “The Fewtrell et al piece in the BMJ has not provided any new evidence on this issue - it raises questions, but does not answer them. It was neither new research nor a proper review, but simply opinion. It cites a range of sources, many of which are of poor quality, or not relevant to the issues in question, or misrepresented.” What is known is that the issue of infant feeding provokes inflamed debate and opinion in the UK whenever the subject is mentioned in the media.

Fewtrell's article also examined infection rates, quoting a US study, which found that infants who were exclusively breastfed for more than six months had lower risk of pneumonia and recurrent otitis media than those breastfed for four to six months.

Again, Professor Renfrew believes this to be incorrect: “Breast milk is full of substances that aid the absorption of iron. There is a wide range of other ways in which breastfeeding affects the health both of infants and of women, including ongoing active immunity for the child, and prevention of breast cancer in mothers.”

A change of policy?
The debate raises many questions about aspects of the WHO policy, including the fact that it is not country specific and does not address variations in health between developed and developing countries. Janet Fyle, Professional Policy Advisor at the RCM, believes that the recommendations are appropriate for women in the UK and that it isn't enough to call for a change in policy without properly examining the evidence: “Some commentators refer to the fact that we aren't in the developing world but that doesn't mean we shouldn't advocate policies that are in the interests of mothers and babies in the UK. We cannot change policy just because it suits a certain group of people. We confuse parents enough. If we want to have a discussion around the appropriateness of extending breastfeeding for six months we should do so in a sober fashion.”

Ms Fyle believes that the call to review guidance about breastfeeding in the UK is misguided and plays into the hands of the formula milk industry: “We are not forcing women to breastfeed for six months. The policy is saying that from a public health perspective, breastfeeding for six months is an imprint. I appreciate that the group have their reasons for generating debate but we must not ignore the evidence base for the recommendations to breastfeed for that long.”

Perhaps the argument is best looked at in terms of the drive to increase breastfeeding rates in the UK. Are we doing enough to promote breastfeeding? What advice should health professionals be giving women? A lack of training in the area for midwives and health visitors has often been raised as the reason for the apparent preference for formula milk among UK women, and this area needs to be addressed, according to Dr Fewtrell: “We could do with a lot more practical support to help [women] breastfeed because it isn't that straightforward; and if they don't have close female relatives around to help them it can be difficult.”

Education about infant feeding for young people in secondary education could be key to encouraging women to choose breastfeeding over the bottle; but the reality is that many are unwilling or unable to breastfeed and this needs to be taken into account by health professionals advising women in their care, as Janet Fyle says: “From a public health perspective, we say breastfeeding for six months, based on the evidence, is the most appropriate thing for you to do. Then we can deal with the mothers who are not able to breastfeed for one reason or another, because we know not everyone can do so.”

Mary Renfrew concludes that the debate has done nothing but harm and will only encourage the trend for women to reject breastfeeding in favour of formula: “All this sorry episode has done is, once again, undermine confidence in breastfeeding, despite the very strong evidence that breastfeeding matters more to both infant and maternal health than any other single intervention. It will undoubtedly have helped to boost the sales of formula worldwide, and has upset many women across the world who have done their best for their babies by breastfeeding them.”

The debate is not about the fact that breast is best - as the authors of the study say they feel that it is - but whether we can discuss occasions where alternatives might be appropriate. As things stand, this may not be possible given the emotions currently surrounding the subject of infant feeding.