WHO breastfeeding recommendations under attack from industry-funded scientists

The BBC, the Guardian and other media are carrying stories about a comment piece from four authors published in the British Medical Journal today. This is not a new scientific study - it is a review of existing research selected by the authors and has been published in the 'Comment' section of the BMJ. Three of the four authors of the piece, Mary Fewtrell, Alan Lucas and David Wilson, receive funding from the baby food industry. Prof Lucas in particular plays a key role in advising the UK baby food industry, and has opposed the WHO recommendation for many years. In 2003 he went so far as to appear for the defence when one of the largest baby food companies, SMA Wyeth was successfully prosecuted for illegal advertising by Trading Standards.

www.babymilkaction.org/press/press31july03.html

http://www.babymilkaction.org/update/update33.html#2

http://www.babymilkaction.org/www.babymilkaction.org/update/update29.html#2

http://www.babymilkaction.org/www.babymilkaction.org/update/update23.html#11

Baby Milk Action expects this comment piece and the media coverage it is generating to be used by companies in their attempt to weaken national policies and legislation requiring complementary foods to be labelled for use from 6 months. In the UK, baby food companies are already labelling complementary foods for use from 4 months of age despite Government policy recommending 6 months exclusive breastfeeding or formula feeding.

When looking at the authors' comment piece, the following points should be borne in mind:

• The four authors are not attacking the recommendation that breastfeeding continue alongside complementary foods or the WHO recommendation of breastfeeding into the second year of life and beyond. Baby Milk Action is concerned about misreporting of the paper, with headlines such as, "Breastfeeding 'not always best'" or "Recommendation to breastfeed for 6 months challenged". Please post examples as comments to this articles, with links if possible.
• This is not a new scientific study - it is a review of existing research selected by the authors and has been published in the 'Comment' section of the BMJ.
• WHO’s policy arose from a systematic review of 3,000 studies on infant feeding. See The optimal duration of exclusive breastfeeding and Guiding principles for complementary feeding of the breastfed child. WHO has issued a statement today (14 January 2011):

WHO's global public health recommendation is for infants to be exclusively breastfed for the first 6 months of life to achieve optimal growth, development and health. Thereafter, infants should be given nutritious complementary foods and continue breastfeeding up to the age of 2 years or beyond.

WHO closely follows new research findings in this area and has a process for periodically re-examining recommendations. Systematic reviews accompanied by an assessment of the quality of evidence are used to review guidelines in a process that is designed to ensure that the recommendations are based on the best available evidence and free from conflicts of interest.

The paper in this week's BMJ is not the result of a systematic review. The latest systematic review on this issue available in the Cochrane Library was published in 2009 ("Optimal duration of exclusive breastfeeding (Review)", Kramer MS, Kakuma R. The Cochrane Library 2009, Issue 4). It included studies in developed and developing countries and its findings are supportive of the current WHO recommendations. It found that the results of two controlled trials and 18 other studies suggest that exclusive breastfeeding (which means that the infant should have only breast milk, and no other foods or liquids) for 6 months has several advantages over exclusive breastfeeding for 3-4 months followed by mixed breastfeeding. These advantages include a lower risk of gastrointestinal infection for the baby, more rapid maternal weight loss after birth, and delayed return of menstrual periods. No reduced risks of other infections or of allergic diseases have been demonstrated. No adverse effects on growth have been documented with exclusive breastfeeding for 6 months, but a reduced level of iron has been observed in developing-country settings.

• Keeping recommendations under review is good practice and randomised controlled trials are also in progress; the four authors are pre-empting the results of these and do not refer to the 2009 review published by the Cochrane Library.
• The four authors imply that delayed introduction of solid foods may be linked to increased obesity - this is total conflict with the studies which show that early introduction - particularly of sugary foods is an important factor behind the obesity epidemic. Breastfeeding may actually help in the development of taste receptors.
• The argument to introduce solids at 4 months to prevent coeliac disease and allergies was summarised by ESPGHAN in late 2009 and was considered by many to be flawed. see our press release: http://www.babymilkaction.org/press/press23dec09.html
• The UK Scientific Committee on Nutrition (SACN) and the Committee on Toxicity (COT) are reviewing the evidence on solid foods and coeliac disease. The draft opinion is NOT FINAL BUT Is on the SACN website with the Agenda papers for next week's SACN meeting. See paper SMCN/11/01 downloadable from http://www.sacn.gov.uk/meetings/sub_groups/maternal_child_nutrition/19012011.html
• SACN use international growth charts to describe the optimal pattern of infant growth in the UK (UK-WHO charts). These are based on studies of babies in 7 countries around the world and no significant difference was found between their growth profiles. The proposal from the four scientists that babies are treated differently depending on where they live conflicts with this research evidence. The mean age at introduction of solids to this cohort of breastfed infants in the WHO studies was 5.4 months (or "..about 6-months").
• The UK policy is to introduce complementary foods at around 6-months and progress responsively, in line with individual babies' progress and acceptance. Not all babies need solids at the same time: in every aspect of infant development there is a wide range of normal. Very importantly the introduction of the new policy in 2003 has been associated with a marked reduction in the numbers of mothers giving solids very early (i.e. before 4-months). Since it is widely accepted that very early introduction carries greater risk (particularly of coeliac disease), the UK policy could be considered from this perspective a success.
• The practice of ‘baby-led weaning’ is becoming more widespread, where babies are allowed to play with appropriately prepared solid foods and decide for themselves when to eat. Experience in this area suggests that babies naturally start to ingest complementary foods at around 6 months of age, when various developmental factors (hand-eye coordination, mastication ability etc) come together. This may be an evolved natural behaviour that has been lost through the practice of spoon feeding prepared paps. Further research is required in this area.
• Marianne Monie, Chair of the nationwide Breastfeeding Network, made an important point about the risk of swine flu: “The evidence supports introducing food when a baby is developmentally ready at around 6 months. Introducing food or infant formula before that time increases the risk of infections. Questioning the wisdom of the six-month guideline at a time when babies are at risk of catching swine flu is unfortunate, because exclusive breastfeeding reduces the risk of secondary infections that can be serious enough to need hospital admission. Parents should not feel pressured into rushing their baby onto solid food. Waiting until around six months gives another two valuable months of additional protection against chest and stomach infection."

Response from Joanna Moorhead:

http://www.guardian.co.uk/lifeandstyle/2011/jan/14/breastfeeding-comment-joanna-moorhead

Response from UNICEF UK:

http://www.babyfriendly.org.uk/pdfs/unicef_uk_response_to_BMJ_article_140111.pdf