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Audrey Naylor, MD, DrPH
In 1979, the World Health Organization (WHO) established a global recommendation that exclusive breastfeeding should be continued for the first four to six months of an infant's life. This recommendation influenced national policies and programs, maternity leaves and day care practices, regulations regarding marketing and labeling of baby foods, clinical services and public attitudes regarding "normal" parenting. Over the more than two decades since that recommendation was made, the understanding of the remarkable benefits of breastfeeding for both mother and infant has grown significantly along with evidence that increased morbidity and mortality was associated with discontinuing exclusive breastfeeding before six months.
During the past five years, many organizations and individuals increasingly expressed concern about the recommendation. Little action occurred until March of 2000 when a group of expert technical consultants, gathered together by the WHO to discuss infant and young child feeding, made a public and formal request for a change in the recommendation. As a result of this, the WHO commissioned a systematic review of the more recent published studies of the morbidity and mortality associated with introducing complementary foods at four, five and six months of age. Though over 3000 articles were given consideration for inclusion in this review, only 19 were determined to be well enough designed and carried out to actually be included in the review process. In March of 2001, as a result of this review, an expert
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consultative group urged that the recommendation for exclusive breastfeeding be changed from the earlier " four to six months" to "six months".
To add to the understanding of how long babies should be exclusively breastfed, Wellstart, with support from the USAID funded Linkages project, coordinated a review of the development of readiness of normal infants to discontinue exclusive breastfeeding. Four topics were examined including development of the gastrointestinal tract, the immune system, oral motor development and maternal reproductive and lactation physiology. This review also completed in March 2001 indicated that from the developmental perspective the normal term infant is more likely to be ready to begin complementary foods at six months of age or beyond.
Thus in Geneva on May 18, 2001, with evidence from the review of community based outcome studies as well as the biologic development of the infant, the World Health Assembly officially approved the long hoped for change and instructed the World Health Organization to recommend six months of exclusive breastfeeding. It will now be important that each of us active in promoting and protecting breastfeeding do all that we can to assure that any mother interested in reaching the new global goal receives the support needed to succeed. In the long run it will be the accumulation of success that will prove the importance of the recommendations made on May 18, 2001.
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