FEEDING OF INFANTS FROM BIRTH TO TWO YEARS
Dr. C.R.Banapurmath, MD, DCH, MNAMS, FIAP*, Dr. Shobha Banapurmath, MD, DCH**, Dr. Nirmala Kesaree, FRCP, FRCP, FIAP, DABP, DCH (London)***
Professor of Pediatrics, JJM Medical College, Davangere National Convenor, Breastfeeding & Lactation Management Committee of IAP Karnataka State Co-ordinator, BFHI , Karnataka State Co-ordinator, BPNI *, Consultant Pediatrician and Secretary, BPNI KSB **, Director, Bapuji Child Health Institute & President, BPNI KSB. ***
Feeding of infants from birth to two years is important to any culture or creed. The way in which a community supports its mothers to bring up its future generation has long standing impact on the humankind itself.

Mother plays a central and pivotal role in nurturing her young one. Woman has unique powers. She only can further the human race. She carries the baby for nine months (3 trimesters) within her womb. After birth she has all the capacity in herself to nurture and bring-up her young one. For the first 6 months (2 trimesters) baby needs nothing other than mother's milk. Throughout the first 2 years, it is again mother's milk, which is the main stay of laying a sound foundation for the future life of the child.
Salient Practical Guidelines for Optimal Breastfeeding
  • Motivate the mother for exclusive breastfeeding for 6 months during pregnancy itself
  • The baby should be put to the breast within the first hour of birth
  • Encourage prelacteal feeds
  • Practice "Exclusive Breastfeeding" for 6 months of life
  • Breastfeed as often as the baby wants to feed
  • Ensure proper positioning while breastfeeding (suckling should be from both nipple and areola)
  • Feed from both breasts (one breast should be emptied before starting on the other side)
  • Continue breastfeeding for two years in addition to the home made complementary foods
Some Important Scientific Facts About Infant Feeding
  • Mother's milk is the complete nutrition for the baby from birth up to about 6 months
  • No other milk, food or drink is required. Babies should be breastfed within ½ to 1 hour of birth. They should be given Colostrum - the yellowish milk during first 2-3 days
  • Nothing should be given before the first breastfeed. Bottle-feeding is unnecessary and even harmful for babies. It is the leading cause of diarrhea in babies
  • The mother can continue breastfeeding during sickness without any harm to the baby
  • Commercial available milk is always inferior to mother's milk
  • Solid foods should be introduced after about 6 months of age
  • Breastfeeding should be continued well into the second year of life
  • All mothers can successfully breastfeed their babies

Breastfeeding has been going on since mammals evolved 230 million years ago on our planet. It was then the obligatory way to feed the young ones. Artificial feeding came into vogue with industrial revolution in the 19th century. The dairy business flourished with advances in the processing and preserving the milk and the development of special formulas for special needs (e.g., preterm babies). Aggressive promotion, not only enticed mothers into preferring the bottle to the breast but even made people believe that "formula feeding is so simple, safe and uniformly successful that breastfeeding no longer is worth the bother"1. But scientific research during the last three decades has clearly proved that breastfeeding provides the most suitable nutrition to the baby, protects it against infections, allergies and asthma, promotes physical, physiological, motor-mental and psycho-social growth and development and gives protection against some adult diseases such as diabetes, hypertension, ischemic heart disease and some forms of malignancy2. In addition, it benefits the mother in various ways like reducing anemia and breast and ovarian cancers, saves money for the family and the nation, helps fertility control and is eco-friendly 3.
The current scientific literature on breastfeeding and complementary feeding that leads us to draw a policy recommendation of BPNI to enable all concerned working on this issue to make use of this paper to develop local guidelines. Besides this, it also addresses the issue of exclusive breastfeeding for working women and the need to have special growth reference standards for breastfed children.
Exclusive Breastfeeding & Its Duration
With much of research into benefits of breastfeeding reported in 1980s to reposition breastfeeding, a new set of definitions evolved that included 'exclusive breastfeeding' which means that the baby receives nothing else other than breastmilk. It was well established that exclusive breastfeeding is the normal way to feed young babies. This took about a decade for this definition to be understood and still to make a it a practice, it requires a great effort in a bid to increase the percentage of babies who are exclusively breastfed during first six months of life.
It has been observed that the beneficial effect of breastfeeding is maximum when it is exclusive 4. However, there is some confusion about the duration of exclusive breastfeeding. A general recommendation for introducing complementary foods between 4-6 months dates back to the Innocenti Declaration of 19905a. This has led many care-providers to recommend complementary foods at 4 months of age. Many mothers interpret this as 4th month and introduce complementary foods on completion of 3 months. Since the Innocenti Declaration, a number of papers have been published which suggest that babies should be breastfed exclusively until about six months of age and that there is no growth advantage if complementary foods are introduced early. This is true even for the low birth weight babies. Some of these papers are reviewed here. Guldan and his associates 6 observed in rural Sichuan infants that not feeding rice before seven months of age and not giving commercial supplements was associated with better growth. Diaz and his coworkers 7 followed the physical growth of 1217 infants from birth to 12 months; 100% of these were exclusively breastfed for one month, 63% for six months and 24% for 12 months. They concluded that breastmilk is sufficient to support adequate infant growth during the first six months of life and that supplements need not be recommended before six months.
Lartey and others 8 followed 216 normal Ghanian children from one month of age to 18 months. They observed that the rates of diarrhea increased if the complementary foods were introduced between four and six months. They stressed that introducing complementary feeding after six months of age improved growth by lessening morbidity.
Dewey and coworkers 9 compared low birth weight term babies (1500-2500 Grams) who were exclusively breastfed for six months with those exclusively breastfed for four months and then given complementary foods twice daily while continuing breastfeed. They found no significant difference between groups in weight and length gain during the intervention period or later up to 12 months age. Early introduction of complementary foods decreased the breastfeed intakes. Similar observations were made in earlier studies also 10,11. Hop et al 12 observed that early introduction of complementary feeds was associated with poorer growth.
Vestgaard and co-workers 13 followed 1656 Danish infants from birth and assessed the development of some selected milestones around the age of 8 months. The sample was divided into four groups on the basis of the duration of exclusive breastfeeding (0-1, 2-3, 4-5, = 6 months) and was adjusted for social and other confounding factors. Those predominantly breastfed for six months or more were found to be 1.4-2.5 times more likely to have attained the selected milestones than those with least breastfeeding.
A meta-analysis of 20 studies 14 distributed the sample into five groups on the basis of the duration of predominant breastfeeding (4-7, 8-11, 12-19, 20-27 and = 28 weeks) and compared their weighted means with those of predominantly formula fed infants. The breastfed babies in each group had significantly higher levels of cognitive function and the benefits increased with the duration of breastfeeding. The preterm babies derived more benefits from breastfeeding than the full term babies.
UNICEF (UNICEF, Nutrition Section, NY 22 Nov. 99) could not identify any current studies that would support introduction of weaning foods from 4 or 5 months while there are reports of higher incidence of infections and allergies8,12-17 due to early initiation of weaning foods and has no compensating advantage in growth.
The World Health Assembly resolution (WHA 47.5, 1994) urged Member States for fostering complementary feeding practices from about six months and further WHA resolution 49.15 (1996) reaffirmed this. The WHO however, recommends that infants should be fed exclusively on breastmilk from birth to 4 to 6 months (WHO: Infant Feeding Recommendations 11 Nov 1999). In the opinion of WHO "although, future scientific information and better understanding of variable impact of individual and population circumstances may well warrant a change one day, present scientific evidence confirms the suitability of WHO's long standing infant feeding recommendation based on initial technical review and discussion in 1979". But on 13-17 March 2000, twenty consultants had gathered in Geneva for Technical Consultation to assist WHO and UNICEF on Infant and Young Child Feeding. They recorded that during the last 10 years after Innocenti Declaration, sufficient scientific (including epidemiological) evidence has gathered for changing the recommended duration of exclusive breastfeeding to about six months. They requested that this statement be included in the official published report of the proceedings of this Technical Consultation. This, however, is only the opinion of the experts but not an official document of the WHO.
During the last three years, many organizations have recommended exclusive breastfeeding for six months or for about/around/at least six months. These include World Alliance for Breastfeeding Action (WABA) and International Baby Food Action Network (IBFAN), the two key international organizations working on breastfeeding and related issues. Other organizations like INFACT Canada, La Leche League International, Nursing Mothers' Association of Australia, Wellstart International, Linkages Project: Academy for Educational development, American Academy of Pediatrics (AAP) and Indian Academy of Pediatrics (IAP) also endorse similar recommendations. By now, the policy of exclusive breastfeeding for about six months is accepted in 61 countries (Naylor A: Statement circulated at the Global Technical Consultation on Infant and Young Child Feeding, March 2000, Genera).
Most of the recommendations use a general term like "around", "about", "at least" so that introduction of the complementary foods could be a little earlier or later depending on the situation. After all it cannot be exactly on the next hour or day of completing six months.
The benefits of exclusive breastfeeding for six months are likely to be much more to infants at high risk (e.g., preterm and those staying in unhygienic environment) than full term babies of affluent class staying in clean homes. Except in the rarest cases, no additional foods or fluids are necessary and in fact they can be harmful, introducing infection, triggering allergies and filling the stomach so that the infants take less breastmilk 18,19.
Complementary Feeding
Beginning at 'about six months', breastfeeding should be complemented with appropriate solid foods. Complementation and replacement of breastfeeding are two separate components of introducing complementary foods. It is important to avoid replacement of breastmilk. The additional feed should not be so much that the breastmilk production is reduced 20. The solid foods should be introduced gradually but breastfeeding continued as often as before. Functional maturation of the neurological, gastrointestinal and renal systems influence the possibility of successful feeding at different ages 21. By the age of six months, the gastrointestinal functions are adequate to deal with the weaning foods while the kidneys can easily handle the solute load especially under conditions of low fluid intake. Mashed and chopped foods are acceptable between 7 and 12 months while family foods are acceptable usually after 12 months of age. The complementary foods should be prepared fresh from the usual home foods 22.

During the initial period, the complementary foods should be given one or two times after the breastfeeding and not in its place. By 8 months the child should receive complementary foods between breastfeed at least three times in a day and at least 4 times a day in the second year. Flavor, aroma, consistency and variety affect the intake of complementary foods.

The prospective growth enhancing effect of breastfeeding continues into the second year. Breastfeeding should therefore be sustained in the second year but in the low socio-economic community in developing countries, child survival may require mother's milk through the third year of life 23-26.

Feeding an infant should be a pleasurable time for both baby and mother. Introduction of semi solids from 6 months onwards should be a gradual and unhurried affair. Weaning means the process of gradual and progressive transfer of the baby from breastmilk to the usual family or adult diet. Weaning does not mean stopping breastfeeding.
Complementary food should be
  • High in energy
  • Easy to digest
  • Semi-solid in consistency
  • Low in bulk and viscosity (not too thick)
  • Fresh and clean
  • Inexpensive and easy to prepare
  • Important practical points

From 6 months:
  • Mash all food
  • Give semi-solid food; do not over dilute
  • Start with one or two teaspoons
  • Over 3 to 4 weeks increase to 50-60 g or half of a cup (or one banana) a day
  • Continue breastfeeding

From 6 - 9 months:
  • Amount of food is gradually increased
  • Variety of food is increased
  • Continue breastfeeding

From 9 - 12 months:
  • More variety of household food can be added
  • Can eat almost everything cooked at home (softened and without spices)
  • Continue breastfeeding

From 12 - 24 months:
  • Needs about 1000 calories or roughly half the amount that the mother eats
  • Child should eat all foods cooked at home. No special cooking needed
  • Continue breastfeeding
Growth Standards For Breastfed Babies
In 1983, WHO recommended health standards established by the National Center of Health Statistics (NCHS) as best suited for international reference". The Indian Academy of Pediatrics (IAP) recommended the 50th centile of the Harvard standard for weight as the standard reference weight (SRW) and 80% of it as the lower limit of normal 28. Although the recommendation was with an objective of bringing uniformity in the grading of protein energy malnutrition, the charts are routinely used in assessing the weights of all children. The lower limit of normal (80% of SRW) lies between the 3rd and 5th centiles of the Harvard Standard, which means that in practice, the IAP accepted the Harvard Charts as reference charts.
Studies conducted in various countries, affluent as well as developing 6,7,29-33, reveal that growth curves of breastfed children differ from the NCHS curves. The NCHS charts represent children with restricted genetic and ethnic background (Caucasians from Europe and America) and children who were mostly bottle-fed 21, 34, 35. Even the recommended dietary allowances (RDA) are based on such children. It is now known that the energy intake of the breastfed infants is often less than the RDA 36. Even after the age of six months, when other foods comprise an increasingly large proportion of the total intake, the energy intake of the breastfed infants is low compared to that of the formula fed, even when the quality and quantity of the food offered is similar 37. When breastfed infants are assessed using the NCHS charts, they are likely to be mistakenly identified as faltering and complementary food introduced earlier than necessary. The need to have new growth charts based on the breastfed infants belonging to the upper socioeconomic strata is obvious (WHO Working Group on Infant Growth, WHO/NUT/94-8. Geneva 1994). This should be treated as a top priority in research related to breastfeeding. It is not difficult. At least one hospital in India32 is using the follow-up clinic its own charts for weight, length and weight for length established on breastfed infants. A WHO sponsored Multi center growth reference study is underway, it is likely to give us reference growth standards for breastfed children in a couple of years.
Exclusive Breastfeeding for Working Mothers
The ILO Maternity Protection Convention 191, 2000 recommends provision of paid maternity leave for 18 weeks. This does not facilitate exclusive breastfeeding for six months. An infant who receives only expressed breastmilk in the absence of the mother is considered exclusively breastfed (WHO/CDD/SER/91.14). ILO convention also recommends provision of breastfeeding breaks and facility for breastfeeding and for expression of breastmilk at the workplace. Unfortunately, these recommendations are rarely followed.
Another way to facilitate exclusive breastfeeding for about six months is to extend the maternity leave to about six months. Pandit Jawaharlal Nehru had said that 'A nation marches on the tiny feet of its children'. Ensuring exclusive breastfeeding for about six months is an important initial step towards attaining healthy future for the nation. The states of Haryana and Punjab in India and at least seven nations in the world have sanctioned maternity leave for six months or more12 (WABA). In Norway, the Government provides leave for 42 weeks with full pay or 52 weeks at 80% pay. In Sweden, the parental leave (shared by mothers and fathers) is for 18 months with 90% of salary for the first 15 months19.
Conclusions
Recommended duration of exclusive breastfeeding and introduction of complementary foods pose a challenge to the scientific community. Except in some rare cases, breastfeeding is all that an infant needs till about six months of age.
The earlier recommendation of 'exclusive breastfeeding for 4-6 months is based on the WHO / UNICEF meeting on Infant and Young Child Feeding in 1979. This '4-6 months' is vague and that many women are likely to introduce foods at 2-3 months so that infants will be eating well by fourth month. New scientific evidence and the fact that many countries have adopted this policy and recommendations of key international agencies favors a change in having a new recommendation.
"The infant should be exclusively breastfed from birth to about six months, at which age complementary feeding should be provided along with continued breastfeeding".
Complementary foods should be suited to the child's ability and aptitude for flavor, aroma, consistency, thickness and variety. In the initial period, complementation should be addition to and not a replacement of breastfeed. Breastfeeding should be continued for two years and beyond.
Complementary foods should be suited to the child's ability and aptitude for flavor, aroma, consistency, thickness and variety. In the initial period, complementation should be addition to and not a replacement of breastfeed. Breastfeeding should be continued for two years and beyond. There is an urgent need to establish growth charts based on breastfed children since the growth curves of breastfed infants differ from those currently used and since growth, especially the weight, is the most commonly used parameter for ascertaining the adequacy of breastmilk. When the currently recommended charts are used, breastfed children are likely to be considered as faltering and given complementary foods early.
The infants of working mothers are at a disadvantage. They are most likely to be fed non-human milk and complementary foods much earlier than recommended. It is necessary to ensure that facilities for continuing exclusive breastfeeding are made available at the work place and that the maternity leave is extended to cover the six-month period of exclusive breastfeeding.
A review of the relevant literature published during the last 10 years and of the statements/recommendations/resolutions by various world bodies reveals that almost since 19935b, 38, the recommended duration of exclusive breastfeeding is "about six months of age". There seems to be some inertia in the propagation and acceptance of this recommendation. Efforts must be made that all concerned have this information and feel convinced about it so that exclusive breastfeeding for about six months is actively promoted.
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