Duration of exclusive breast feeding in low income countries

Breast feeding continues to be the norm in low income countries but the period of exclusive breast feeding after birth is often short. Accumulating evidence of the benefits of exclusive breast feeding led to a recommendation by the WHO that it be done for the first six months of life. Studies in low income populations, have shown that fluids in addition to breast milk are unnecessary to maintain hydration. It has found that breastfed infants in the first six months of life who were given additional foods had a twofold to threefold higher mortality from diarrhoea and pneumonia in comparison with infants who were exclusively breastfed. Introducing fluids or foods into the infant's diet before 6 months of age did not benefit growth. One of the issues that was not addressed in the recent recommendations was the adequacy of exclusive breast feeding with regard to the infant's intake of iron and zinc. Evidence shows that in settings where newborns, especially those with low birth weight, have low iron and zinc stores they may have a need for more of these minerals than is usually provided in breast milk. In such settings the fluids and foods usually provided to young infants are poor sources of these minerals and may actually reduce the bioavailability of iron or zinc from breast milk. Exclusive breast feeding is still recommended, but supplementation with iron and zinc may be needed from about two months of age. HIV transmission from infected mothers to their infants through breast milk leads to the second major issue. In low income settings infant mortality is often high, and the rates of death from diarrhoea, pneumonia, and other infectious diseases would probably increase without the protection afforded by breast feeding. HIV infected women who choose to breast feed exclusively may reduce the rate of HIV transmission in comparison to partial breast feeding. A practice of exclusive breast feeding for up to six months followed by rapid weaning from breast milk may therefore provide the best approach until programmes to provide alternatives to breast milk are more fully implemented. A WHO expert consultation recommended exclusive breast feeding for six months, emphasising that this recommendation applies to populations while recognising that some mothers will be unable to, or choose not to follow it. Means to ensure the adequacy of iron and zinc intake and to reduce HIV transmission in exclusively breast fed infants need to be sought. Evidence shows that exclusive breast feeding for six months is feasible and is acceptable to mothers in low income countries, as shown by the success of programmes promoting exclusive breast feeding in many low income countries.