Abstract
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Few if any debate the appropriateness of these recommendations for mothers in the developing world given the reality in those countries of a significant infectious disease risk, the unavailability, all too often, of adequately nutritious CFs and the economic realities of the population. In contrast, in the developed world, such as the United States where the rate of EBF is much lower, that is, at 3 months it is 44% whereas it is only 22% at 6 months, 2 this recommendation is best adhered to with “lip service.” Of note, the 2020 United States Healthy Peoples Goal for 6 months of “exclusivity” is 25%, surely not anticipating adherence to either the WHO or the AAP recommendation. Similar statistics from Europe confirm this phenomenon of a varied but still small percentage of mothers providing EBF at 6 months (United Kingdom 1%, Czech Republic 17%, Sweden 9%, and The Netherlands 39%. 3
These wide variations in the 6 months EBF rates no doubt also reflect a variety of cultural factors that impact on patterns of infant feedings beyond basic nutritional issues. What reinforces the “tolerance” if not the actual legitimization of the feeding of CFs at a younger age than the WHO 6-month recommendation is the lack of any significant evidence-based data regarding any major medical disadvantage (save for a possible decrease in nonlife-threatening gastrointestinal and upper respiratory infections) in those infants fed a cow's milk-based formula. In addition there is no reported difference in growth, body composition, or energy intake between those infants fed food earlier than 6 months and those adhering to the 6-month recommendation of breast milk exclusivity. 4
As we all know, the publication of the Learning Early About Peanut Allergy trial 5 served as the basis for the recommendation of the National Institute of Allergy and Infectious Diseases 6 that peanut-containing food be introduced into the diet of infants who are at a high risk for developing peanut allergy as early as age 17 weeks or more. This recommendation no doubt further reinforces the concept that there may even be an advantage to earlier feeding of CF. Although peanut allergy prevention addresses a limited target population, these recommendations have been interpreted by many to legitimate feeding other allergenic foods (egg, fish, gluten, and even cow's milk protein) after the 17th week postpartum. 7
This confusion of recommendations was recently addressed by myself and colleagues in response to the use of the phraseology that nonrisk infants should be fed “age appropriate and in accordance with family preferences and cultural practices,” without a designation of any recommended targeted number months of duration of exclusivity. 8 Clearly the absolute and categorical proclamation of 6 months no longer holds. Dr. Di Marino from Italy in fact states that in Italy, the four to six recommendations are being interpreted by “most pediatricians as starting at 4 months.” 9
The purpose of this editorial is not to provide a review on the subject of complementary feedings. This has been comprehensively presented in a most balanced and practical manner by Fewtrell and colleagues representing the European Society for Pediatric Gastroenterology Hepatology and Nutrition Committee on nutrition. 3 Rather, I wish to raise two questions and make some of my own categorical recommendations.
1. Can we justify continuing to make a single categorical, global, and universal recommendation for all populations in all geographic area? Shouldn't the realities of the countries with its different health priorities (infectious disease as compared to allergy prevention), its economic situation, and the availability of nutritious CFs dictate the recommendation? One should acknowledge that the proverbial shoe cannot and possibly should not fit all and, to mix my metaphors, by continuing with universal recommendations, we may be shooting ourselves in the foot. Simply put, one may conclude that the world will not come to an end if we get away from this universal straightjacketing policy.
2. Isn't it time to redefine the term “exclusive breastfeeding”? Clearly we should distinguish substituting human milk with a cow's milk product (be it formula or whole fresh milk) from supplementing with nutrient-rich CFs while the milk feeding continues to be exclusively human milk. Ingesting water surely cannot be biologically equated with food ingestion, but all these “violations of exclusivity” are labeled the same. Unfortunately, reviewing the literature reveals that this distinction is rarely, if ever, made. Thus the interpretation of data regarding any differences between three or six months of exclusivity is at best problematic, as we do not know whether the exposure was to bovine or meat or grain protein, or who knows what (maybe just a drop of water).
Until these two issues are addressed and resolved, what needs to be recommended is as follows:
1. EBF for term infants should be for a minimum 17 weeks. 2. Introduction of CF to term infants who are developmentally ready for semisolid food (including “allergenic” foods) can begin after 17 weeks. In particular this includes the introduction of peanut-based foods for infants at risk for developing allergy. Introduction of CF should not be delayed beyond 6 months. 3. Whole bovine protein in any form (formula or fresh milk) should be avoided and the milk feedings should continue to be human milk during the introduction of CF in the 4–6-month period and beyond, preferably for at least 1 year. 4. Whole cow's milk should be avoided for at least 1 year postpartum.
And remember, these recommendations are for term infants who are born in the developed world and, thus they should not change the recommendation of the WHO and like for the maternal–infant dyad in the developing world.