Breastfeeding

Why breastfeeding?

Breastfeeding is the natural way to feed infants and young children. Breast milk alone provides all the nutrients an infant requires to grow well until about six months: carbohydrates, protein, fat, vitamins, minerals, digestive enzymes, hormones and water in a perfectly balanced mix. After the age of six months, breastfeeding, with appropriate complementary foods, continues to contribute to an optimal infant’s and young child’s growth.

Perhaps more important than its nutritive function is the protective role of breastfeeding. Breast milk contains antibodies from the mother that help defend the baby against infections. It also contains other substances that limit the growth of or kill harmful germs. Finally, breast milk passes live cells on to the baby that will enhance its defences. The exact composition and properties of breast milk are still unknown, but during evolution mammals developed it first as a protective substance and only later as a food (Oddy, 2002). In addition, the composition of breast milk changes in response to the needs of the baby, during a feed, during the day, and over time. Hence, it adjusts to each infant's needs for growth and development.

The WHO recommends breastfeeding children up to two years of age or beyond

The WHO Global Strategy for Infant and Young Child Feeding (WHO, 2002g) recommends that infants be exclusively breastfed for the first six months of life. Thereafter infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond. UNICEF, as well as many governments and professional associations, have endorsed and adopted the WHO recommendations. Exclusive breastfeeding for the first six months and subsequently breastfeeding with appropriate complementary foods secure optimal infant’s and young child’s growth, development and health (AAP, 2005).

Alternatives to breastfeeding should only be used in medically recommended situations

Different types of artificial milk are marketed for replacement of breast milk. However, despite continuous efforts to improve the composition of these formulae, a mass industrial product will never equal breast milk. Its composition will never change during a feed and it will never contain antibodies and live cells specifically designed for that baby. Formula feeding, therefore, should only be used in medically recommended situations. For example when infants are affected by rare diseases such as galactosemia, maple syrup urine disease and phenylketonuria (for more details see Medical reasons for formula feeding).

Whatever the reason for replacing breast milk with formula, mothers should be warned about the possible harms of artificial feeding. In particular, mothers using powder infant formula, the most commonly acquired product on the market, should be alerted that this is not a sterile product and that it should be stored, prepared and administered to the baby in a safe manner (WHO/FAO, 2007).

Lack of breastfeeding is associated with an increased risk of diarrhoea, lower and upper respiratory tract infections, type 1 and type 2 diabetes, childhood leukaemia, SIDS, obesity and more. Lack of breastfeeding is also associated with increased risks for the mother, such as pre-menopausal breast and ovarian cancer (Ip et al., 2007). For more details see Consequences for individual and society.

Also see the EUphact Diabetes.

EU comparisons are restricted by limited available data

Not all EU member states gather regular data on breastfeeding. Even less produce data on trends. The ECHI shortlist recommends using the rates of breastfeeding at 48 hours and at 3 and 6 months as indicators. The WHO-HFA database offers data for breastfeeding at 3 and at 6 months of age (see Percentage of infants breastfed at 3 months of age in the EU-27; Percentage of infants breastfed at 6 months of age in the EU-27).

Accurate comparisons are difficult because of methodological issues, especially in the case of breastfeeding at 48 hours. For example, the precise definitions of breastfeeding may differ: the data reported in the table may include different degrees of exclusive breastfeeding. Also, the methods through which data were gathered may be different: from surveys using the last 24 hours as recall period to interviews administered to mothers of older children asking them to recall the breastfeeding status at 3 or 6 months after much longer time (Cattaneo et al., 2000; Aarts et al., 2000; Cattaneo et al., 2005).

Very roughly, considering data currently available in the WHO/HFA database and other data reported by countries participating in EU-funded projects (Cattaneo et al., 2005), it would appear that initiation, exclusivity and duration are relatively high in Scandinavian countries, lower in Belgium, France, Greece, Ireland and UK, and in between in all other countries. More accurate comparisons of breastfeeding rates are currently impossible.

Breastfeeding in the EU is below WHO guidelines but on the rise

Though accurate comparisons are impossible, it is clear that the rates of initiation, exclusivity and duration of breastfeeding in EU countries fall short of WHO recommendations. This is also true for the rest of the world, including low income countries (Lauer et al., 2004). The scanty data available from EU countries, however, often at sub-national level, seem to indicate an upward trend since the mid 1990s (see Trends in percentage of infants breastfed at 3 months of age; Trends in percentage of infants breastfed at 6 months of age). A limited number of studies have also shown that the rates of breastfeeding initiation, exclusivity and duration in the EU are lower in lower social class families and particularly in children of less educated mothers (Yngve & Sjostrom, 2001).

There is a need for appropriate and comparable data collection systems

WHO recommends using standard definitions for breastfeeding and standard methods for collecting data worldwide, see Definitions of breastfeeding recommended by WHO. These have been used in surveys worldwide over the past 15 years, but not in EU countries. More recently, WHO has proposed a standard set of eight “core” and seven “optional” indicators on infant and young child feeding based on the above definitions, see Set of infant and young child feeding indicators proposed by WHO. Data collection systems in European countries should adopt WHO definitions, methods and indicators to ensure that future data collected can be used in international comparisons. Data collection should also be carried out using an equity lens. This requires the collection of data on the socio-economic determinants of infant feeding (e.g. data on the numbers of low income mothers breastfeeding) (Yngve & Sjostrom, 2001).

Lack of breastfeeding negatively impacts the health of children and their mothers

A lack of breastfeeding is associated with an increased risk of the following disorders and illnesses in childhood and through adult life (Ip et al., 2007; Horta et al., 2007; León-Cava et al., 2002):

• lower and upper respiratory tract infections (including acute otitis media);
• diarrhoea;
• atopic dermatitis and asthma in young children;
• overweight and obesity in older children and adults;
• high blood pressure and total cholesterol;
• type 1 and type 2 diabetes mellitus;
• childhood leukaemia and other childhood cancers;
• SIDS;
• necrotizing enterocolitis in preterm newborns.

Based on these well known associations, formula fed infants may have a slightly increased risk of mortality in high income countries (Chen & Rogan, 2004). This effect is, however, much more significant in low income countries, where it is estimated that increasing the rate of exclusive breastfeeding at six months to 90% could prevent 1.3 million childhood deaths per year (Jones et al., 2003).

In general, the harm associated with lack of breastfeeding is proportional to the exclusivity and duration of formula feeding: the longer the lack of breastfeeding and the shorter its exclusivity, the greater the harm.

Lack of breastfeeding is also associated with increased risks for the mother, in relation to the following disorders and illnesses:

• type 2 diabetes;
• pre-menopausal breast and ovarian cancer;
• shorter periods of amenorrhea and intervals between births;
• possibly postpartum depression.

There are direct and indirect costs associated with a lack of breastfeeding

Breast milk is virtually free; powder infant formula, which is much cheaper than liquid and special formulae, costs between 10 and 25 € per kg. Together with the cost of preparing, storing and administering artificial milk and sterilizing the equipment, this is an extra cost that families must meet if they decide to formula feed their babies. This cost is proportionally higher for low income families. In addition, the health and social system has to meet the extra cost of care caused by the increased risk of illness. This extra cost has been estimated at around 100-300 € per infant in the first year of life (Ball & Wright, 1999; Cattaneo et al., 2006). The total cost, including the extra health care needed later in childhood and through adult life, may amount to several billion dollars a year in a country like the USA (Weimer, 2001).

In addition to direct health care costs there are indirect costs, such as the time parents will spend at home and in the hospital, the cost of transport and the periods of absenteeism from work. Finally, formula feeding has a heavy impact on the environment, due to agricultural activities around cow milk production, the industrial process of manufacturing and distributing the product, the energy needed to maintain the cycle of production, transport and consumption, and the management of an enormous amount of waste.

Also see EUphacts Diabetes, Overweight, Blood pressure and Breast cancer.

In the following summary, the main causes for non-exclusive or shorter-than-desirable breastfeeding are listed.

Problems with the initiation of breastfeeding lower breastfeeding rates

In some EU countries only about 50% of mothers initiate breastfeeding. Even where initiation rates are higher and approach 100%, many mothers experience breastfeeding problems during the first few weeks, such as breast and nipple pain and complications due to inadequate support for good positioning and latching. Low initiation rates and high incidence of initial problems are typical of bottle feeding cultures. The first measures, therefore, are the development of national and local policies that present breastfeeding as the natural choice, to increase the rate of initiation, and that provide adequate initial support. Such support is best provided by maternity services that apply the Ten Steps for Successful Breastfeeding of the Baby Friendly Hospital Initiative.

Good initiation alone, however, is insufficient. Support for the continuation of exclusive breastfeeding up to six months is also necessary. Baby Friendly primary and community health care services with supportive and competent health workers and/or peer counsellors, are essential to ensure adequate continuation of breastfeeding. For more details see The Seven Steps for the Protection, Promotion and Support of Breastfeeding in Community Health Care Settings. Mothers of preterm and sick infants, who may benefit even more than healthy term infants from exclusive breastfeeding, need special support at both hospital and community level.

Early use of formula or other breast milk substitutes also lower breastfeeding rates

One of the main causes of non exclusive or shorter-than-desirable breastfeeding is the early and inappropriate use of formula or other breast milk substitutes. This is often the effect of aggressive marketing of these products by manufacturers and distributors. In 1981, to reduce this effect and protect breastfeeding, WHO and UNICEF adopted the International Code of Marketing of Breast Milk Substitutes (WHA, 1981). The Code has since been updated regularly by relevant Resolutions of the WHA. The EU Directives that transposed the International Code into EU and national regulations in 1991 and 2006 (EC, 1991; EC, 2006b), fall short of the minimum requirements recommended by the Code. More rigorous regulations need to be adopted and enforced to protect breastfeeding in the EU.

Need to return to work and inaccurate advice lower rates between 4 and 6 months of age

Exclusive and non exclusive breastfeeding rates tend to fall, among infants who continue breastfeeding, between 4 and 6 months. This is often due to inaccurate advice mothers get from health professionals and lay people, including relatives and friends. Another common reason is the need for many mothers to return to an active work life (Hawkins et al., 2007). These two problems obviously require different solutions.

The provision of inaccurate advice can be tackled by equipping health professionals and other people giving advice to mothers with better knowledge and skills, while a mother’s need to return to an active work life can be overcome with better social protection for working mothers (Galtry, 2003; Staehelin et al., 2007). Better social protection may include allowing working mothers who wish to breastfeed as recommended to do so by extending the time of maternity leave to six months. Afterwards, working times could be made flexible, with so called breastfeeding breaks to either breastfeed if the child is nearby or pump and store breast milk for later use. Workplace crèches or similar arrangements should be set up whenever possible, and adequately equipped. Maternity leave and breastfeeding breaks should be extended for mothers of twins and preterm or sick infants. Better social protection for working mothers has been shown to be beneficial to overall child health, in addition to breastfeeding (Tanaka, 2005).

Fear of environmental contaminants in breast milk may stop mothers from breastfeeding

Breast milk is often used to detect persistent residues of man-made chemicals that accumulate in human bodies; this applies in particular to fat soluble substances, such as dioxins and PCBs, because of the high fat content of breast milk. These contaminants can enter the body through ingestion, inhalation and skin contact, and pose a definite risk to the foetus. The fear that this will occur may also stop some mothers from opting to breastfeed. All the organisations using breast milk to monitor levels of environmental pollutants, however, stress that their purpose is not to harm breastfeeding and emphasise that the advantages of breastfeeding are not compromised by any potential risk from residues of these contaminants in breast milk. Research has also shown that the presence of these environmental contaminants in breast milk is not associated with health risks; on the contrary, breastfeeding appears to reduce or revert the damage caused to the newborn by the exposure to the same contaminants during pregnancy (Ribas-Fito et al., 2003).

Alcohol and substances derived from smoking, as well as drugs such as heroin, cocaine and amphetamines, are also passed to the infant through breast milk, and directly through passive and non-passive smoking, and may harm its health (see the EUphacts Alcohol use, Smoking and Drug use for more detailed information) (Howard & Lawrence, 1998; Little et al., 1989). The use of these substances should be discontinued during pregnancy and lactation, or at least reduced to a minimum. Individual counselling should be available to assist parents to make appropriate decisions. If an occasional alcoholic drink is consumed, breastfeeding should be avoided for two hours afterwards (Mennella, 2001).

Breastfeeding should be promoted as the natural way of feeding among the general public

Parents usually make decisions on infant feeding shortly before or early in pregnancy. The choice, however, can be influenced by attitudes established long before a pregnancy is even contemplated. It is therefore important to represent breastfeeding to the general public as the natural way to feed infants, and create an environment where breastfeeding becomes the normal, easy and preferred choice for the vast majority of parents. It is important that boys and men should also receive infant feeding information because, as potential future fathers, they will have an important supportive role to play in the decision to breastfeed and in the success of breastfeeding.

Health education classes and antenatal services offer effective promotion tools

Health education classes specifically dedicated to breastfeeding and regular contacts with competent health workers, lactation consultants and/or peer counsellors, are an effective way to promote the initiation and extend the duration of breastfeeding, especially when continued after childbirth (Renfrew et al., 2005). The use of printed material alone, such as information booklets given to mothers, has not been found to be effective.

The health care system should not only ensure easier access to services but also identify and remove barriers (e.g. geographical, economic, linguistic, and cultural) that may make women less likely to use existing antenatal care services. For example, women from ethnic minority groups, adolescent mothers, women from lower socio-economic groups, and women who left school early may not use antenatal care services even when access is freely available. This may require alternative service provision specifically adapted to meet the needs of these vulnerable expectant mothers.

Baby Friendly Hospital Initiative offers effective support for breastfeeding mothers

Optimal care for the effective initiation and establishment of exclusive breastfeeding is the same whether the birth takes place at home, at a birth centre, or in a maternity hospital setting. In all these places, the application of the Ten Steps for Successful Breastfeeding of the Baby Friendly Hospital Initiative has proven to be effective (Kramer et al., 2001; Cattaneo & Buzzetti, 2001). In particular, rooming-in which allows breastfeeding on demand, results in ample milk production and helps establish an adequate lactation thus overcoming the often perceived problem of lack or insufficiency of breast milk. Hospital stay after delivery, however, is short and tends to become shorter. It is therefore essential that Baby Friendly practices be implemented also in primary health care and community services (see the Seven Steps for the Protection, Promotion and Support of Breastfeeding in Community Health Care Settings for more detailed information).

Some mothers require special support to continue breastfeeding

Women with particular breastfeeding difficulties need timely access to expert help and support to continue breastfeeding; those who stop breastfeeding before they wanted or planned to should be encouraged and assisted to examine the reasons for this, to help reduce feelings of loss and failure, and to ensure this experience does not adversely affect future infant feeding experiences. Mothers of ill or preterm infants need special support to ensure their lactation is maintained while their babies are unable or too ill to breastfeed. They should also get information on the safe handling and storage of expressed breast milk. This support should include the provision of breast pumps and assistance with travel and accommodation to ensure they can be near or with their babies as much as possible.

Social and community interventions should be implemented to support breastfeeding

Collaborative projects involving voluntary and statutory services offering both expert and peer support to breastfeeding families and their social networks are to be encouraged. Supporting and protecting the right of women to breastfeed their babies whenever and wherever the need arises is fundamental. National and local initiatives which promote social acceptability of breastfeeding outside the home should be encouraged. If needed, governments should be urged to put in place legislation which protects a mother’s right to breastfeed in public. All these initiatives should specifically address the needs of women less likely to breastfeed, such as women having their first child, immigrants, adolescents, single mothers and less educated women.

Well co-ordinated and funded policies and plans are needed at a national and local level

Given the importance of a 'warm chain for breastfeeding' for public health, sound national and local policies and plans should be developed and implemented to protect, promote and support it. As stated in the Innocenti Declaration, all governments should establish or strengthen national infant and young child feeding authorities and coordinating committees that will adequately manage and fund planned interventions.

Moreover, policies and plans should make sure that both pre- and in-service training on breastfeeding for all health worker groups, including pharmacists, require a level of competency to be attained that meets best practice standards. Health workers should be trained not only on the scientific foundations and practical details of infant and young child feeding, but also on counselling and communication. In addition to individual communication provided by health workers to mothers and their families, policies and plans should include activities for social communication geared to behavioural and social change. In particular, media portrayals of infant and young child feeding should be monitored and media organisations should be guided and encouraged to depict and promote breastfeeding as normal, achievable and desirable.

Breastfeeding is contraindicated only for infants affected by rare diseases such as galactosemia, maple syrup urine disease and phenylketonuria (some breastfeeding is possible, under careful monitoring, in the latter condition, UNICEF/WHO, 2006a). These infants need special formulae, not the ordinary ones available to the general public.

There are other circumstances where infants may need formula as a replacement or supplement to breast milk for a limited period of time (UNICEF/WHO, 2006a). Examples are:

• infants born less than 1500 g or less than 32 weeks gestational age;
• newborns who have experienced severe stress during delivery;
• infants who are ill or whose mothers are diabetic;
• infants younger than 6 months with severe growth faltering not caused by illness and not reverted by frequent, effective suckling.

A breast abscess does not contraindicate breastfeeding; infants can be fed on the unaffected breast and breastfeeding from the affected breast can resume once the abscess has been drained and antibiotic treatment has started (WHO, 2000e). Women with herpes lesions of the breasts should also avoid breastfeeding until all active lesions have resolved (Henrot, 2002). In the case of maternal tuberculosis and Lyme disease, breastfeeding is safe once the mother has started treatment (WHO, 1998a; Shapiro, 1995). With few exceptions (radioactive iodine, sedating psychotherapeutic drugs, antiepileptics and opioids, cytotoxic drugs used for chemotherapy of cancer) maternal medications do not impede breastfeeding (WHO, 2003b). Even when a mother is drug dependent or an injecting drug user, breastfeeding may not be contraindicated depending on which drug is used (NSW Health, 2006).

The most appropriate option for HIV infected mothers (and for the less frequent cases of infection with human T-cell leukaemia virus) depends on individual circumstances (WHO, 2006g). When formula feeding is acceptable, feasible, affordable, sustainable and safe, which is usually the case in EU countries, avoidance of breastfeeding is recommended. When this is not the case, the availability of health services and of competent counselling and support should be taken into consideration before advising the mother to formula feed.

Also see EUphacts HIV/AIDS and Drug use.

The Code covers breast milk substitutes, including “infant formula, other milk products, foods and beverages for use as a partial or total replacement for breast milk, feeding bottles and teats”. It was adopted in 1981 at the WHA by the majority of Member States to stem the aggressive marketing of formula milk and the resultant rise in infant mortality. Subsequent WHA Resolutions have updated the Code as necessary, to take account of new scientific knowledge and commercial product marketing trends. These Resolutions have the same status as the Code, as reaffirmed by a technical endorsement from the WHO secretariat (WHO, 2006h).

The main provisions of the Code and subsequent WHA Resolutions are:

1. Governments have the responsibility to provide information on infant feeding. Donations of informational materials by manufacturers or distributors should only be made at the request and with the written approval of the appropriate government authority.
2. No advertising of breast milk substitutes to the public.
3. No direct or indirect free samples or gifts to mothers or their relatives.
4. No company sales representatives to contact mothers directly or indirectly.
5. No gifts or personal samples to health workers. Samples provided are to be for professional evaluation or research at institutional level. Health workers should not give samples to pregnant women or mothers of infants and young children.
6. Information to health workers should be scientific and factual.
7. Financial support to health professionals should not create conflicts of interest.
8. All information to mothers should include the benefits of breastfeeding and the costs and hazards of artificial feeding.
9. No promotion of products covered by the Code in health care facilities including no free supplies.
10. No words like “humanized”, “maternalized”, or similar terms, pictures and text idealising artificial feeding on labels.
11. Nutritional and health claims are not permitted for breast milk substitutes, except where specifically provided for in national legislation.

Successful implementation of the Code depends on countries incorporating and enforcing its provisions into their national/regional legislation. The Code, however, states that irrespective of such incorporation, industries should monitor their own practice and conform to the principles and aims of the Code itself. Although sponsorship of health programmes and health professionals, including training, is not prohibited by the Code, the 1996 and 2005 WHA Resolutions cautioned against conflicts of interest. Health professionals may feel they are immune to commercial promotional activities. Social science studies have concluded otherwise: even “small gifts” have an effect (Dana & Loewenstein, 2003).

The EU first transposed the Code into a Directive of the European Commission (EC) in 1991 (Directive 91/321/EEC). This Directive applied only to infant and follow-on formulae and limited their marketing only to infants less than four months of age. In December 2006 the EC issued Directive 2006/141/EC to update and replace the 1991 Directive. The 2006/141/EC Directive extends the marketing limitations to infants up to six months.

Almost at the same time, the EC issued Directive 2006/125/EC on processed cereal-based foods and baby foods for infants and young children. Article 8.1.a of this Directive says that the label of these products must bear a statement as to the appropriate age from which the product may be used; it adds that “the stated age shall not be less than four months”, thus contradicting many national recommendations for exclusive breastfeeding up to six months and the standard set by the Codex Alimentarius. The Directives of the EC are to be transposed into national laws or regulations in all Member States.

In 1990 in Florence, Italy, representatives from 30 countries adopted the Innocenti Declaration, a document that established new strategic objectives to more effectively protect, promote and support breastfeeding.

The four operational targets of the Innocenti Declaration were:

1. to appoint a national breastfeeding coordinator and establish a multisectoral national breastfeeding committee;
2. to ensure that every facility providing maternity services fully practices all the Ten Steps to Successful Breastfeeding;
3. to give effect to the principles and aim of the International Code in their entirety; and
4. to enact legislation protecting the breastfeeding rights of working women and establish means for its enforcement.

In November 2005, an anniversary celebration was held in Florence in which participating delegates discussed and adopted more urgent and necessary actions. The 2005 Innocenti Declaration identifies roles and responsibilities of key players (governments, manufacturers and distributors of products within the scope of the International Code, multilateral and bilateral organizations and international financial institutions, public interest non government organizations) and emphasizes that these responsibilities need to be met to achieve an environment that enables mothers, families and other caregivers to make informed decisions about optimal infant feeding. The Innocenti Declaration 2005 was endorsed by the 2006 Annual Session of UN Standing Committee on Nutrition, and the WHA in 2006 urged Member States to support actions contained in the Call for Action (WHA Resolution 59.21).

Smoking

Alcohol use

Drug use

Breast cancer

Health Inequalities

Diabetes

HIV/AIDS

Overweight

Blood pressure

WHO Europe, health-for-all database

WHO international, global data bank on breastfeeding

UNICEF, breastfeeding indicators

Health EU portal, nutrition

WHO Europe, infant feeding

WHO international, breastfeeding

Breastfeeding promotion in Europe

Promotion of breastfeeding in Europe: pilot testing the Blueprint for action

World Alliance for Breastfeeding Action

International Baby Food Action Network

International Lactation Consultant Association

European Lactation Consultant Association