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Am J Clin Nutr 2007;85(suppl):635S– 8S. Printed in USA. © 2007 American Society for Nutrition 635S
636S FEWTRELL ET AL
Following the 2001 Expert Consultation and the 2002 publica- suboptimal, suggest that exclusive breastfeeding without iron
tion of a WHO-commissioned systematic review (5), the global supplementation through 6 mo may compromise hematologic
recommendation was modified and exclusive breastfeeding is status.”
now recommended for the first 6 mo of life with the introduction “Based primarily on an observational analysis of a large ran-
of CF thereafter and continued breastfeeding for the first 2 y (6). domized trial in Belarus, infants who continue exclusive breast-
This topic has become one of the most debated areas of infant feeding for 6 mo or more appear to have a significantly reduced
nutrition in the past few years. The optimal duration of exclusive risk of one or more episodes of gastrointestinal infection.” This
breastfeeding is often equated with the optimal age for introduc- statement came from findings in a subgroup of infants from the
tion of solid foods. However, because CFs are defined by the PROBIT study, a randomized trial of a breastfeeding interven-
WHO as any fluid or food other than breast milk, breast milk tion in Belarus, which for the purposes of the review was re-
substitutes are regarded as CFs, and formula-fed infants are garded as a developed country. A total of 3483 term infants were
deemed to have received CF from the point at which they receive included in the analysis: 621 had been exclusively breastfed for
formula. Current WHO recommendations focusing on the intro- 6 mo, and 2862 had been exclusively breastfed for 3 mo. The
duction of CF in the context of the optimal duration of exclusive relative risk of one or more episodes of gastrointestinal infections
breastfeeding are therefore difficult to apply to formula-fed in- during the first 12 mo was 0.61 (95% CI: 0.41, 0.93) for infants
fants, yet this group constitutes a significant proportion of exclusively breastfed for 6 mo; exclusive breastfeeding was not
healthy term infants in many industrialized countries. The debate significantly associated with a lower risk of atopic eczema, re-
has become highly politicized. spiratory infections, otitis media, or hospitalization for respira-
In this review, we first discuss the available scientific evidence tory or gastrointestinal infections (9).
relevant to the question of whether exclusive breastfeeding for “No significant reduction in risk of atopic eczema, asthma or
욷6 mo results in benefits to mother and infant compared with
mo causes harm is weak for infants in developed countries and 5. Kramer MS, Kakuma R. The optimal duration of exclusive breastfeed-
that infants should be managed according to their individual ing. A systematic review. Geneva, Switzerland: World Health Organi-
zation, 2002.
needs. This view is widely held among health professionals hav-
6. World Health Organization. Global strategy for infant and young child
ing regular contact with mothers and infants, especially given the feeding. Geneva, Switzerland: World Health Organization, 2003.
fact that it is not consistent with current maternal behavior and 7. Wilson AC, Forsyth JS, Greene SA, et al. Relation of infant diet to
choice in many countries. The authors highlighted, for example, childhood health: the Dundee infant feeding survey. BMJ 1998;316:
the lack of specific recommendations for the introduction of CFs 21–5.
in preterm infants, who have their own specific nutrient require- 8. Kramer MS, Kakuma R. The optimal duration of exclusive breast feed-
ments that are unlikely to be met by a recommendation designed ing. A systematic review. Adv Exp Biol 2004;554:63–77.
9. Kramer MS, Guo T, Platt RW, et al. Infant growth and health outcomes
for healthy full-term infants. Similarly, the data suggest that both
associated with 3 compared with 6 mo of exclusive breastfeeding. Am J
early (쏝3 mo) and late (쏜6 mo) introduction of gluten- Clin Nutr 2003;78:291–5.
containing cereal may increase the risk of celiac disease or wheat 10. Lanigan JA, Bishop J, Kimber AC, Morgan J. Systematic review con-
allergy in at-risk infants (21, 22). cerning the age of introduction of complementary foods to the healthy
Given the increasing evidence that early nutrition and growth full-term infant. Eur J Clin Nutr 2001;55:309 –20.
can have effects not only in the short term, but also on longer- 11. Burdette HL, Whitaker RC, Hall WC, Daniels SR. Breastfeeding, intro-
term health, we believe it is vital that this issue be investigated in duction of complementary foods, and adiposity at 5 y of age. Am J Clin
Nutr 2006;83:550 – 8.
high-quality randomized studies, as recommended by Kramer
12. Chantry CJ, Howard CR, Auinger P. Full breastfeeding duration and
and Kakuma in their systematic review. At the very least, the associated decrease in respiratory tract infection in US children. Pedi-
consequences of the WHO recommendation should be mon- atrics 2006;117:425–32.
itored in different settings to assess compliance and to record 13. Hamlyn B, Brooker S, Lleinikova K, Wands S. Infant feeding 2000.