What follows is an excerpt from my latest book, Milk matters: infant feeding and immune disorder. It is much easier to read in the book itself, which also deals with practical matters related to this issue. Copying the text from an In Design file to this version has been a time-wasting nightmare, and there will be typos: please read the book….
But to avoid looking foolish in print, anyone writing about the issue of the age of introduction of complementary foods to different groups of infants should think about all that follows.
Chapter 7.5 Four months or six? The debate over age
(Note: This chapter was first written as a stand-alone discussion of the issue in historical context. This means there is some repetition of what has already been said elsewhere in the book.)
Be clear about one thing. The World Health Organization (WHO) never gives detailed advice about the use of proprietary infant formulas, except for how to reduce their microbiological risks. Just as with any other industrial product, it’s up to the formula makers to advise about their use.
So what do we know about the best time to widen the diet of either breastfed or formula-fed infants? In Breastfeeding Matters (1985) I argued strongly for 6 months exclusive breastfeeding, and four months formula feeding, even though WHO’s 1978 policy was ‘from four to six months” as the global population norm for the introduction of other foods to breastfed infants.
Following a period in which extensive multi-national research was done to investigate the risks and benefits of introducing other foods to breastfed children, in 2001 WHO changed its policy. As the UK Department of Health summarised the process,
Early in 2000, WHO commissioned a systematic review of the published scientific literature on breastfeeding; more than 3000 references were identified for independent review and evaluation. The outcome of this process was subject to a global peer review, after which all findings were submitted for technical scrutiny during an expert consultation. The WHO revised its guidance in 2001, to recommend exclusive breastfeeding for the first six months of an infant’s life.
What WHO was doing was setting out general population-level guidance as to what research indicates as the optimum age, for breastfed babies in general. No such research has been done, or WHO guidance given, for formula-fed infants. This population guidance acknowledged that individual clinical care is important for the best outcome for any individual baby. Which means that some babies may need to be given other food earlier than, and others may not want it till later than, six months, and doing so is still within the WHO guidelines. The recommendation was never an dictatorial insistence than all babies must be solely breastfed until six months, though it is often misrepresented as that.
The 20th century background
Ever-earlier use of commercial foods for babies became the trend from the 1920s onwards, once industry marketed babyfoods in cans and jars. In 1935 Marriott revised downwards from twelve to six months the recommended age for introduction of other foods. By 1978 most US infants were fed strained foods, mostly gluten-containing cereals, by six weeks of age.2024 The 1975 UK survey found that 40 per cent of children had been given solids before six weeks of age, and 97 per cent before four months (Cow & Gate). Childhood obesity was becoming evident by the 1970s, and the salt and sugar in commercial babyfoods was seen as a factor (which diverted attention from the infant formula they drank.) These concerns triggered discussion and research into the best age for introducing foods other than milk to the infant diet.
In 1980 both UK and US authorities raised the earliest recommended age to four months.2025 This soon mutated into the latest age at which solids must be introduced to all infants. And that has somehow come to seem the traditional age for those whose memory goes back only a generation or two. In fact, it was very recent and not evidence–based so far as breastfeeding was concerned.
For experience with breastfed babies had always indicated that they were perfectly capable of thriving for much longer than four months on breastmilk alone. Sir Frederick Truby King was a New Zealand based doctor who became very influential throughout the British domains. He founded schools of mothercare which emphasised the importance of breastfeeding, while mandating dogmatic schedules that undermined its success; he created commercial baby foods under the Karitane label. Before the Second World War he was better-known than Dr Spock (the famous US paediatrician) among the educated elites who read baby books, and the nurses who advised all mothers. Standard advice from the Truby King camp, in books that circulated widely throughout the British Empire even after the Second World War, was as follows:
Complete breastfeeding until the 12th month or longer may be carried out with great success, provided the mother’s health is satisfactory. Baby should have been given a bone to chew from 6 months onwards; and at nine months … some hard food such as twice baked bread, hard crusts or crisp toast, should be gradually introduced into his diet.
‘Complete breastfeeding’ for this dominant British school of advice meant complete reliance on breastmilk for the nutrients baby needed. The bones and crusts were about tactile learning, not calories. When calories were needed, during the nine to twelve month weaning process for example, the Truby-King house brand of powdered milk, Karitane milk mixtures, were suggested. So some babies at nine and a half months consumed the following:
4 breastfeeds (6am, 2pm, 6pm and 10pm) + 1Tblsp cereal jelly (starch and water) + 240ml Karitane recipe milk mixture + 1/4 tsp Kariol (fish oil emulsion) + a finger of baked wheaten bread (rusk).
The long intervals between breastfeeds would have ensured engorgement and assisted involution of breast glandular tissue, so milk supply would quickly drop. Two weeks later at ten months, the baby got only two breastfeeds (six am and ten pm) and the rest was 720 ml milk mixture plus the Kariol, rusk and cereal jelly. Orange juice was given to prevent scurvy: initially . tsp + . tsp water after three months, increasing to 2 Tblsp juice plus 2 Tblsp water at twelve months. Babies grew on such diets, though not all were happy. Babies had not read the Truby King manuals, and many mothers ignored the advice given in clinics under the influence of Truby King. It is easier to breastfeed than to listen to a baby cry.
But not widening the diet of the breastfed child until nine to twelve months was not just a British practice. Vahlqvist said of Sweden:
In the 1920s it was still customary for paediatricians to recommend semi-solids only at the end of the first year. It came almost as a shock when the renowned Swedish pediatrician Jundell proposed in 1921… that such food might and preferably should be introduced as early as 6 months of age … today, this is usually recommended from 3 months and in practice is often introduced even earlier.2026
Spanish doctors had similar ideas. Gonzalez has an enlightening and amusing appendix which traces changes in dietary recommendations in hispanic medical writing. As he says,
It seems that child feeding throughout the last century has changed almost as much as the length of skirts and the width of ties. Each new generation of doctors has recommended a totally different diet from the previous generation (in other words, different from what they learned in medical school, and different from what they ate as infants.) Each doctor also changed his recommendations as his career progressed.2027
Longer duration of breastfeeding was identified with poverty; women breastfed longer out of necessity. In Whitechapel, a London slum in 1910,
A Jewish woman sits shamefaced before the doctor. ‘11 months on and baby still given the breast, mother?’ The woman makes no reply and the interpreter whispers, ‘Afraid of unemployment, so keeping one breast going as a safeguard.’ They pass out, the wasting mother and the thriving child.2028
Note who suffers here. Not the child. Family income was and is always a factor in infant feeding realities. This visual and mental association of breastfeeding with poverty continues in many countries today, leaving poor mothers vulnerable to advertising that subtly positions ‘Gold’ formulas as proof of higher social status and affluence. (In 2013 “Platinum” formula emerged using milk from A2 herds: what comes next? Diamond?)
So: twelve months, six, or four? How can we know when a baby is ready to eat a wider variety of foods than breastmilk alone?
Indicators of readiness for other foods
Not surprisingly, the baby indicates readiness, via behaviour and physiological markers of development that usually emerge between five and seven months of age. At this age babies may often be sitting nearby or on parental laps at mealtimes, and usually express interest in what their parents are eating.They have head control and better co-ordination, and they can sit up, which facilitates swallowing of the new foods and reduces choking risks. They also
• lose the extrusion reflex, which causes their tongue to push things out of their mouths.
• are interested in exploring new tastes and textures (if these are associated with pleasure, not made aversive by force-feeding)
• can grasp foods and transfer them to their mouths
• can indicate aversion or sateity by refusing food.
• have a more developed gut and immune system
• are developing teeth, the better to handle foods
• have more developed kidneys that are better able to handle a higher solute load
Some babies develop faster than others. Some will not want to do more than play with food (other than breastmilk) until well into the second half of their first year. This was obviously accepted as normal behaviour in the early 20th century. Regular growth monitoring will indicate if a child is under-fed, as the growth curve will falter and cross centile lines. Good growth monitoring can both reassure parents or indicate that there may be a problem. The most commonly cited risks of introducing other foods too late have not been growth concerns, but concerns about iron sufficiency, and food aversion.
Some babies will cope with absurdly early introduction of foods, at a few days or weeks rather than a few months, as had been proved by the 1970s. But as WHO rightly said in 1990, ‘Of course the mere fact that the physiologically immature organism can adapt to a feeding mode that is nutritionally unnecessary hardly justifies its use.’2029 The possible immediate problems of too early introduction of other foods include decreased milk production, decreased caloric intake, iron deficiency, infection, and allergy. The long-term risks include poor food habits, poor appetite control, obesity, hypertension, cardiovascular disease, kidney damage, food allergy and aversion.2030
Patent baby foods: how safe?
Most mammals continue to suckle until they treble their birthweight, before eating other foods. During the 20th century, babyfood companies generally urged giving their products once a baby reached ten pounds (4.5kg) or 3 months, whichever came first. Giving foods to such very young babies requires them to be of an unnaturally fine consistency. This was the baby food companies’ raison d’etre, as they worked out ways to create products whose texture and consistency were tolerated by very young infants. (Similar results were achieved in human history only by maternal premastication and mouth feeding, not a practice likely to be revived, despite its utility and probable high immunological value!)
Industrial baby foods inevitably contain a good deal of water, but need to look like a food, not a drink, to justify their cost and facilitate spoon feeding. Something has to glue the fine solids together. Complex modified food starches were developed to stabilise and suspend the food particles, creating the desired consistency, texture, and shelf-life. Parents are generally unaware that in the scientific community there are still four concerns about such starches. The first relates to the bioavailability of the starch itself. The second is the potential that indigestible starch may have for producing diarrheal symptoms, malabsorption, and changes in gastrointestinal flora. The third is the possibility that modified food starches might be implicated in gastrointestinal disease like Crohn’s ileocolitis. The fourth is the toxicological effect of the chemicals used to modify the starch and their possible mutagenic and carcinogenic properties.2031
Wow. So there are specific risks to widening the diet unnecessarily early, using industrially produced commercial baby foods. Those parents who keep breastfeeding till six months or so and then introduce suitable family foods need not worry about such things, as babies can handle other than super-smooth consistencies. Around six months is NOT an absolute upper limit for exclusive breastfeeding, as history tells us.
Why then did the AAP in 1980 recommend four to six months?
The answer is surprising. Pediatrics records that AAP Committee Chair Professor Lewis Barness was challenged by a fellow paediatrician, Robert Ganelin, to explain why, when the physiological markers suggesting infant readiness – listed on the previous page – clearly emerge between five and seven months, not at three to four. His reply was startling in its honesty.
Trying to convert from previous practices of feeding solids at 1 month of age to the present recommendations must be done step-wise. A compromise was felt to be necessary. For breastfed infants there seems no advantage and some disadvantage to early supplements. When one uses an artificial formula, no matter how good, one must beware of possible missing ingredients. Weighing advantages and disadvantages, the Committee on Nutrition felt that 4 to 6 months of age was reasonable with present evidence.2032
Implicit in Professor Barness’s reply are two things.
The first is a clear awareness that breastfed babies can safely go longer than four months, up to six months perhaps.
And secondly, that formula-fed infants may be at risk if they go any longer than four months on formula alone.
Note this well. The basic reason for adopting four months, with its acknowledged ‘disadvantage’ to the breastfed infant, was the risk to the formula-fed infant of trusting fallible industrial mixes for any longer than that. Barness and the AAP committee were worried about the artificially fed infant, rightly so given the recent damage. What was not mentioned in the reply was the elephant in the room in 1980: the Syntex CHO-Free/Neo Mull Soy formula problem (see page 407) in which babies who relied solely on one infant formula were the most damaged.
Disadvantaging the breastfed (and women) to protect the artificially-fed
This ‘four to six months’ 1980 recommendation changed into “give other foods to all infants at no later than four months.” But why disadvantage breastfed infants – who clearly could go longer on breastmilk alone – because of ‘possible missing ingredients’ [or added contaminants, or nutrient excesses, or antigen exposure] in formula? There simply was no credible evidence base to justify the application to breastfed infants.
There are other overlooked/ignored advantages to waiting until six months, and not just for the infants. Among the important reasons are health gains for lactating women, better able to recharge their body stores with another two months of lactational amenorrhoea, and further protection from hormone-linked cancers, as well as savings in time and money.
Breastfeeding is not free, but it is certainly cheaper than its industrial competitors. And the foods that many mothers introduce at four months are time-consuming and less nutritious infant formula or infant cereal, not a variety of carefully chosen and prepared complementary family foods.
Not until late in the twenty-first century was there a global effort to answer the question of the optimal age to widen the diet of fully-breastfed infants. After those global multi centre studies, WHO, a notably conservative body, proposed six months as a population goal (for the breastfed, remember; they said nothing about the formula-fed) because high-quality research showed that this was best for both mothers and babies. Yet this overdue change would spark a storm of controversy globally. It is also sometimes misrepresented as pressure to breastfeed for doctrinaire reasons, not a scientific assessment of what would be best for most mothers and children.
Health authorities’ reactions
Astonishingly, however, some Western health authorities promptly translated the WHO evidence-based recommendation about breastfed infants into six months’ exclusive breast or formula feeding. Once again Western society’s underlying myth surfaced: that artificial formula is virtually the same as breastmilk, so what applies to breastmilk applies to formula.
What that assumption implies is crystal clear: there is no need for experts to take decades to research an optimum age for exclusive formula feeding: if women’s milk can be relied on for six months, how much more so can its artificial substitute be trusted? (The assumptions are breathtaking when you consider them.) Too many people too often assume that whatever is said about breastfed infants applies to the artificially fed, despite the biological differences that accumulate from birth.
One recommendation or two?
Many interests disliked the idea of six months’ exclusive breastfeeding, for a wide variety of reasons. Healthworkers long exposed to industry’s subtle propaganda about the deficiencies of breastmilk were concerned that breastmilk could not be trusted that long: iron was needed. Some felt that they could not give different advice to mothers than they had in the past, and were uncomfortable about urging six months for formula-fed babies, having assumed – with no logical basis – that what WHO said about breastfeeding should be said to bottle-feeders. Few health authorities seemed to realise that what WHO implicitly demanded was that industry fund research about the optimal age for introducing its foods to the formula fed, before changing from the accepted practice of four months for those infants. Some women felt six months to be unrealistic, an onerous burden that raised the bar for breastfeeding women.
The real issue that industry surely perceived was not articulated publicly. Having two different recommendations for the different feeding groups would begin to unravel the carefully crafted illusion of equivalence between infant formula and breastmilk. National health authorities would be saying clearly to parents, ‘You can trust your own body to supply all your baby needs till six months, but formula is a fallible synthetic product, and no one can be sure that it will supply all your baby’s nutritional needs. Since your bottle-fed baby’s body stores of some nutrients will be depleted by around four months, it’s sensible to widen their diet just in case formula has got something wrong: too much, too little.’
True, sensible, not hard to do: but unacceptable to the powerful. Very little discussion took place about the ramifications of increasing the age for formula-fed infants beyond the point where in utero body stores of specific nutrients could be exhausted, even though that had been the stated justification for the four months recommendation in 1980.
Resistance and controversy
Industry sought advice and support in the health community, and lobbied hard to keep the old single recommendation for all infants, preferably the (since 1980) usual four to six months. In the UK, a group titled INFORM was created by SMA Nutrition (then owned by Wyeth), Nutricia and HJ Heinz, all formula producers. INFORM’s address was c/o IDFA, the Infant and Dietetic Foods Association. In 2005 a substantial INFORM report, Infant Feeding in the UK,2033 was disseminated, an impressive-looking but error-riddled piece of
special pleading targeted at health professionals. That particular document seems to have received little global coverage: the press was perhaps sceptical about a report created, funded and published by industry, however eminent the Expert Advisory Panel which endorsed it before publication.2034 That Panel was chaired by Professor Alan Lucas, and included Professor Mary Fewtrell. The document argued for four to six months, not six,for all infants.
What really fed this controversy worldwide was a 2011 opinion piece in the British Medical Journal.2035 Its lead author, Professor Mary Fewtrell, and her colleagues, have all done sterling work on infant feeding issues, and strongly support breastfeeding. However, they are UK-based academics, and very few UK women currently breastfeed at all, much less exclusively, for 6 months. Listening to a recent presentation, it seems to be empathy for women which underlies Fewtrell’s determined resistance to the six months’ guidance (or perhaps she just has a perversity gene from Irish ancestors, like me, and questions most things! Who can know another’s motivations?) Fewtrell was also an author of the 2008 European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) statement2036 which had supported the WHO ‘exclusive breastfeeding to around six months’ as ‘a desirable goal’, but was more widely quoted for its quite prescriptive ‘not before seventeen, not after twenty-six weeks’ variant on the WHO position.
Like their INFORM document, this Fewtrell et al BMJ article suggested that the evidence for six months exclusive breastfeeding was not sufficient, though it was better than the evidence had been for the four months’ guidance in 1980. The BMJ article supported that once controversial older four to six months range, that women had adjusted to following because trusted health professionals told them to.
The BMJ article was initially described in press releases as research, or a review, when it was neither, just an opinion piece by people who seemed to think that because most women do not feed exclusively to six months (true), they could not do so (untrue, especially if health professionals spoke with one voice about the importance of exclusive breastfeeding).
The article is still being cited as authoritative opinion, despite multiple errors of fact and assumption, and even internal contradiction.2037 (Such is the power of the world press, when read uncritically, or by those who want to endorse a particular opinion as authoritative.) So the article needs to be critiqued in some detail.
The multiple industry connections of some of the article’s high-profile authors and their previous work on this very topic, as industry consultants on the INFORM project in 2005, was nowhere mentioned by the BMJ. It would have helped if BMJ had put this direct connection on record beneath the article, as those industry connections may also have helped explain the extraordinary global reach of this damaging opinion piece. Respect forthe BMJ has been eroded by its willingness to publish and publicise such an article and then to follow it up with an ill-informed commentary2038 that many in the lactation community – myself included – thought was both patronising and offensive. Many of the Rapid Responses to the article are worth reading,2039 as are the letters which BMJ did publish.2040
But industry connections don’t explain opinions held by reputable academics – though the connections can influence assumptions, and in rare cases, provide motives. There have to be other concerns and issues of substance involved for such researchers to contradict WHO. Two concerns often raised in connection with the age of introduction of other foods are the risk of iron deficiency, and the effects on acceptance of other foods.
The iron furphy
As Wikipedia records, a “furphy is Australian slang for a rumour, or an erroneous or improbable story, but usually claimed to be absolute fact. Furphies are usually heard first or secondhand from reputable sources and until discounted, widely believed.” No better word could be found to describe the concern about possible iron deficiency if breastfed babies are not given other foods at four months. Industry used this furphy globally as a marketing tool in the 1980s. The BMJ opinion piece talked of the catastrophic effects of iron deficiency anaemia, without providing any evidence that exclusive breastfeeding to six months posed a risk of clinical iron deficiency. What is more, the catastrophic effects cited were from anaemia of a different origin, not in breastfed children. The study referred to in the BMJ article was independently analysed by Adam of Dianthus Medical as follows:
Chantry et al’s study is described by Fewtrell et al as showing that ‘US infants exclusively >breast fed for six months, versus four to five months, were more likely to develop anaemia and low serum ferritin’. Did it? Chantry et al looked at two separate cohorts of children, and measured iron deficiency by three different measures: low serum ferritin, low haemoglobin, and a history of anaemia …[the latter] based mainly on reports by the parents, with no medical verification … the results were highly inconsistent…’
As Adam concluded,To cite that paper as evidence that exclusive breastfeeding for six months increases the risk of iron deficiency anaemia therefore strikes me as misleading.2041
Me too, Adam. How could that happen, when one of the BMJ article co-authors, Professor Alan Lucas, has previously expressed concern about iron deficiency only for exclusively breastfed babies given low-iron solids after six months, and small for gestational age (SGA) babies under six months? And of course, babies who have suffered any bleeding problems.
In healthy breastfed children given iron-poor weaning foods (which most are not in the UK) deficiency can emerge around nine months. Obviously that is not relevant to discussions about whether to introduce solids at four versus six months of age.
One problem factually linked to low iron levels in breastfed babies is the use of low iron solids that chelate breastmilk iron2042 and make it unavailable. This is hardly a reason to introduce solids at four months rather than six! For, as discussed elsewhere in this book, the young baby has a complex interactive metal transport uptake and system (copper, zinc, iron), which can be deranged by the addition of other foods, with unpredictable consequences.
The quality of complementary foods is important, and in the past only WHO multi-mix policies have properly addressed the issue of what to give. I am pleased to see that the Australian Infant feeding Guidelines are now stressing the need for nutrient-dense iron-rich first foods, not the 1970s advice to give cereals and vegies with no fat and little protein.
In the late twentieth century many young Western babies were given a virtual Pritikin weaning diet, and breastmilk (their sole source of quality protein and fat in some cases) was then blamed for any growth faltering or iron deficiency. I repeat: there has been no evidence of iron deficiency under six months in thriving breastfed infants, unless there has been significant infant blood loss post-partum. And new research now indicates that excess iron may foster gut pathogens, increase free radicals, and be as damaging to cognitive development as too little. (See page 359.)
A question of taste?
The BMJ article also expressed concern about possible breastfed-infant refusal of different tastes if introduction of other foods was delayed until six months, rather than begun at four months. Perhaps the authors were unaware of those wildly differing patterns of solid food introduction over the twentieth century. Our parents and grandparents grew up to eat their vegies despite very different patterns of introducing beikost (mashed food).2043 Until 1911, some US experts stated that green vegetables absolutely must not be given before thirty-six months; by 1929 this dropped to nine months. In 1935 Marriott suggested six months for solids, which was daringly early compared with UK and other recommendations of nine to twelve months. After that it was downhill all the way as manufacturers made products available in ever smoother gel or liquid forms. No one did comparative studies to check outcomes of such different patterns of introduction of ‘weaning’ foods other than milk. Taste aversion caused by infant feeding seems not to have been a problem that concerned doctors then.
However, research now suggests that there is indeed a sensitive early period before four months of age when infants need to be exposed to different flavours, or they resist them later. I have no reason to quarrel with that, because breastmilk always exposes infants to a huge variety of tastes.2044 That being the evolved norm, I would assume that all babies should experience a wide range of tastes from birth. This fact is yet another reason to vary infant formulas and give solids to formula fed children at 3-4 months, but it is irrelevant to breastfed children. It is a reason to encourage the breastfeeding mother to eat a diverse diet, and to persist with breastfeeding throughout the whole year or more that the child is exploring new tastes, and to share those foods with the baby.
The simple but salient fact that breastmilk flavour reflects the mother’s diet is rarely noted in such discussions, and was not in the BMJ article. Yet babies exclusively breastfed for three or more months have been shown to eat more vegetables as preschoolers than formula-fed children.2045 And recent research shows that eating vegetables is associated with lower rates of adult metabolic disease, also without commenting on whether breastfeeding might be the primary cause of both these desirable outcomes.2046 Similarly, a national US study found that children fed new foods under six months were 2.5 times more likely to dislike new foods and to eat a narrower variety of foods; while children exclusively breastfed to six months were much less likely to become picky eaters.2047 As taste researchers said,
‘The general principles observed are likely of broader significance, indicating a fundamental feature of mammalian development and reflecting the importance of familiarising infants with flavors that their mothers consume and transmit to breast milk.’2048
Research does indicate that there may be valid concerns about artificially fed infants and taste aversions, concerns not raised by the BMJ authors so concerned about exclusively breastfed children. Research shows that just experiencing tastes on the lips without eating the foods improves acceptance of new foods. That raises concerns about infants fed nothing but bland sweet formulas: how do they adjust to a wide range of flavours later? And what consequences arise from the bitter tastes of some denatured protein infant formula mixes which smell and taste so vile2049 that they can be used as sprays to protect crops from insect predation? (Another good reason to wash all fresh foods if you are milk-allergic. No one expects their tomatoes to be coated with casein, but they might be.) Common sense suggests that continuing sweet and flavoured milk mixtures into the second year of life (via so-called toddler/growing up milks) could also be of concern in this regard. Human infants are simply not designed to have bovine milks and sugars as the dominant part of their diet until two years of age, but this is increasingly the case. And with that comes picky eaters, some stuffed full of formula and refusing other foods while their parents sigh and say, well, it’s nutritional insurance, at least he drinks his formula.
A question of textures?
Another concern often expressed in this discussion of when to introduce non-milk foods to infants, is that ‘late’ introduction of solids might lead to possible infant inability to handle other textures, lumps in food and so on. However, this concern is totally irrelevant to the discussion of four versus six months, or breastmilk versus formula, even though the INFORM report used it in that way. Six months is not late introduction. The study cited was of children not introduced to any lumpy food until around ten months of age, who are more likely to reject such foods at fifteen months of age.2050
That cited study also failed to explore why these particular babies were not given finger foods or some lumpy foods to explore before ten months of age. Was this a normal population of infants and mothers? If so, were mothers over-reliant on industry-packaged foods and formulas, all smooth and readily swallowed from 3 months on? Are packaged strained foods the direct cause of widespread aversions to real food? (Which they taste nothing like,if the ones I tried were typical.) Or were these lumpy-food-intolerant toddlers in fact hard-to-feed food-sensitive babies who rejected all efforts by mothers to get them to eat? Were they simply consuming too much white liquid to be hungry?
Different potential causes would emerge from careful consideration of the individuals in this population of babies. But there is no lesson here for those arguing about four versus six months for breastfed babies. Except perhaps that authors need to read cited literature studies for themselves, and not rely on others’ interpretations. In fact, babies breastfed for longer are more likely to be eating a wider variety of foods at the age of two.2051 As I’d expect given the basic science.
A systematic review is emphatically not what this BMJ article was. However, such professional systematic reviews have been published since then. Did genuinely objective reviewers support retention of four to six months as a universal recommendation for all infants, or suggest it was dangerous to breastfeed solely to six months? No.
The Cochrane Collaboration is a database of reviews done according to strict criteria for assessing the quality of evidence provided, and strong disclosure requirements for contributors. There you can review the evidence that supports the conclusion that: although infants should be managed individually, the available evidence demonstrates no apparent risk in recommending, as a general policy, exclusive breastfeeding for the first six months of life in both developing and developed country settings.2052
That is precisely what WHO said. The European Food Safety Authority (EFSA) in 2009 and the UK Scientific Advisory Committee on Nutrition (SACN) in 2011 reached the same conclusion as the Cochrane Review and WHO. Breastfed babies in general can safely be fully breastfed till six months, and there is no advantage to introducing other foods before that time provided the individual baby’s growth trajectory is satisfactory.
All these reviews carefully refrained from suggesting when formula-fed infants might, could, or should have their diets widened; there is too little scientific evidence about artificially fed infants for it to be reviewed systematically. The real-world evidence we have since 1980 is for the results of feeding other foods beginning at four months, but how do we interpret what we see: as proof that children survive, certainly; but do they thrive normally or become obese too easily on the advice given everywhere since 1980? Where’s the multi-centre growth reference study that includes details of the formulas fed, with protein at 1980s levels and 2010 levels to assess outcomes? Where’s any guidance for bottle feeding parents?
Parents: too dumb to know what their babies eat?
As mentioned earlier, the ESPGHAN 2008 recommendation for the introduction of solid foods was ‘not before seventeen weeks, not after twenty-six weeks’. There was no distinction between the breastfed and the not-breastfed infant. What was the justification for their support of the old position of four to six months, in a statement which has been thoroughly critiqued by other European experts with breastfeeding expertise?2053 I think that the reason given absolutely undermines the credibility of the 2008 ESPGHAN Committee on Nutrition, Fewtrell included. As a parent I find it both amusing and insulting. The reason they gave in 2008 for not wholeheartedly endorsing the WHO position was not evidence-based or scientific. They had no further evidence than WHO. No, they simply said:
devising and implementing separate recommendations for the introduction of solid foods for breast-fed infants and formula-fed infants may present practical problems and cause confusion among caregivers.
Basically, that’s saying that parents would find two recommendations confusing. As though ESPGHAN isn’t confusing them by saying six months is a ‘desirable goal’ but seventeen weeks on is OK! Yet separate recommendations are made for a variety of different groups of infants: former prems, the allergic, vegetarians, vegans,2054 various religious communities … And Norwegian parents seem to manage: Norway is cited in a European Food Safety Authority (EFSA) document2055 as having two recommendations: after six months for breastfed infants (though earlier if needed after four months), but between four and six months for all infants not breastfed. If Norway can make such recommendations, why not others? Are Norwegian parents so much smarter? They do seem to know whether their babies are exclusively breastfed or not. However, even in Norway the concern may be academic, as in 2006 less than half of Norwegian infants were in fact exclusively breastfed to even four months, and just 9 per cent were solely breastfed to six months.2056 (Still, that’s nine times the number in the UK!)
Do parents take notice of such recommendations? Yes they do. The UK’s Scientific Advisory Committee on Nutrition published clear evidence of this.2057 From 1990 to 2005 giving solids before three months dropped from roughly seventy percent to ten percent; and giving solids between four and six months rose from five percent to almost fifty percent.
While in 2005 only a tiny number were already following the 2003 UK policy advice to feed solely to six months, SACN saw this as indicating the need to promote the message more widely, as parents did listen to professional advice. This has been made more difficult by the media’s prominent reporting of dissenting opinions, which have left parents confused.
The 2012 AAP statement
In 2012 the American Academy of Pediatrics, once divided on the subject, issued a strong statement supporting the WHO position. The 2012 Policy Statement on Breastfeeding reaffirmed the AAP recommendation of exclusive breastfeeding for about six months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for one year or longer as mutually desired by mother and infant: and says that ‘Because breast-feeding is immunoprotective, when such complementary foods are introduced, it is advised that this be done while the infant is feeding only breastmilk … Mothers should be encouraged to continue breastfeeding through the first year and beyond as more and varied complementary foods are introduced.’2058
Regrettably, however, the AAP, like ESPGHAN, has not yet dealt with the issue of complementary foods for artificially fed infants. They have to date ignored their own 1980 realisation that two different groups of children are involved, and have not affirmed the fact – obvious to them all in 1980 – that the diet of the formula-fed child should be widened before the exhaustion of body stores, which would be less than four months for some infants, and four for normal term babies.
In that 2012 AAP statement on breastfeeding they have said nothing to help the majority of American parents who are not solely and successfully breastfeeding to six months, much less those millions bottle-feeding from birth. As the European Food Safety Authority (EFSA) said, ‘There are numerous publications which discuss the timing of initiating complementary feeding with regard to breast-fed infants, whilst the literature on nonbreast-fed infants is limited.’2059 Why this neglect of key questions for the still-dominant form of Western infant feeding? All too hard? No one wants to know the answers?
Questions this raises
So let’s do some critical thinking about why anyone might want to challenge WHO’s goal of getting infants solely and well breastfed to six months (though given other food earlier if needed). Why might someone want four to six months left as the time of introduction of other foods for all children? In the world of realpolitik there are some impolite questions to ask.
- Who would have gained, or would gain, from the continuation of the 1980 four months recommendation? A. The commercial babyfood and infant formula industries, sometimes the same entities.
- Is there a major public health gain to telling parents that all babies should be offered solids at four months? A. None that I can see, though perhaps it possibly does protect the bottle-fed babies from deficiency.
- Does that gain outweigh the possible loss of breastfeeding, the loss of lactational amenorrhoea and its benefits for mothers, the increase in infections and cancer risk for mother and child, the poorer quality nutrition of the breastfed infant? A. Absolutely not.Or, if the single recommendation were to be six months for both sets of babies,
- Does the public health gain of having one recommendation outweigh the unpredictable risk of harm to artificially fed babies after infant body stores are exhausted? Or the additional and increasing cost to parents? A. We can’t know without proper research. If bottle-fed babies aren’t given other food until six months, the deficiencies of formula might show up. But many nations, including Australia, have now adopted the WHO six months recommendation and applied it for all babies, not just breastfed ones. That’s a whole new experiment which should be carefully monitored.
Why does industry not want six months for both? Do they know that if bottle-fed babies weren’t given other food until six months, deficiencies of formula would indeed show up?
Or is it that a twofold approach to the issue of when to introduce other foods to infants makes plain to the simplest person that breastmilk and formula are not ‘so close nowadays’ as to make no difference? That myth has been the basis of their multi-billion dollar success.
What I would like to know about widening the infant diet
Factually, breastfed and formula-fed infants are already different from one another by four months, because their diet is different over those four months. So some questions that occur to me are:
Should a breastfed infant on a low- (but highly bioavailable) protein diet consume the same complementary foods as a formula-fed infant on a higher (but poorer quality) bovine milk-protein diet?
Does the use of low calorie high-fibre cereals and vegetables that became common Western weaning advice suit the artificially fed infant, but not the breastfed one?
Human milk nutrient bioavailability drops when other foods are added: eg, some solids reduce iron absorption. Doesn’t that mean that nutrient-dense foods of good caloric, protein and mineral value are needed, not the low-calorie, low-iron vegies or fruit often suggested
When will there be research looking at weaning diets for infants known to be at greater risk – the mixed-fed and formula-fed?
When will parents be given the information needed to devise suitable complementary foods from good family foods, not overloading the artificially fed child with protein, sugars, starches and fats, and not underfeeding the breastfed child with low calorie vegetables
Does the high-carbohydrate bland taste of many commercial infant formulas and baby foods cause later taste aversions and obesity?
Do different infant formulas require different weaning diets? If lower-protein formula has been used for four solid months, should the weaning diet be richer in protein than if a higher-protein formula was used? Professor Alan Lucas (a coauthor of the Fewtrell article, and chair of that 2005 INFORM Expert Advisory Panel, remember) has said clearly that infant formulas are not all the same, that even small differences may have significant effects.2060 (My emphasis.) Each infant formula is a liquid mixed diet, not a single food.
What about that seemingly inflexible upper limit of six months, or ESPGHAN’s twenty-six weeks? Where is the research to say that this is an absolute upper limit? (I see it as essential only for artificially fed infants.) The fact that this is definitely a suitable age to begin offering foods does not mean that parents should panic if their fully breastfed and thriving baby shows no interest. Many babies do no more than play with other food initially, accidentally ingesting tastes as they explore. There is no need for concern while they continue to thrive on breastmilk alone, being charted on the appropriate WHO child development graphs. Yet much anxiety is generated by the breastfed baby who doesn’t immediately guzzle down other foods as soon as they are offered. All sorts of suggestions are made to speed up the sometimes slow rate of acceptance by babies to whom food means breastmilk.
Surely happily-thriving completely-breastfed babies under six months are the least of our concerns. So why has all the focus of media attention been on them, especially when they still constitute a tiny minority of all babies, even in Nordic countries? It makes very little sense that we worry so much about breastfed babes and so little about the artificially fed. But that works to sell products!
Science can’t yet tell us what or when to give other foods to artificially fed infants (i.e., those babies consuming mixed-origin solids suspended in water, presenting as white liquids).Why? Because we don’t know in detail either what they need, or what they’re getting (see page 399). Loud-mouthed infant formula advocates are strangely silent on these issues of just when and what to give formula-fed babies as distinct from breastfed ones: in fact many seem to go on relying on formula, rather than focussing on transitioning the child to a life without formula by twelve months. WHO rightly considers breastfeeding the human norm for all populations, and simply cannot advise about proprietary products whose intimate details are commercial secrets. Thus where independent evidence-based advice for artificially feeding parents is needed, there is little other than dubious industry advice.
What parents need to understand
There are two basic problems with the advice that all babies need to widen their diet by six months of age.
The first is the failure to appreciate past experience which says clearly that
- some –not all – children can be safely solely breastfed past six months, extending the period during which other foods can be gradually introduced, and reducing the pressure on mothers of thriving breastfed babies who refuse other foods until seven or eight months; and
- some – not all – formula-fed children really need to widen their diet by four to six months, as body stores may be depleted, and formula is fallible.
The second, and the most basic problem, is the underlying attempt to create a single onesize-fits-all recommendation about the age of introduction of foods other than breastmilk or formula despite the differences between both infants’ and mothers’ histories, exposures to allergens, and reactivity.Solely breastfed children of solely breastfed mothers are not the same as children partially breastfed from birth or formula fed from birth; children gestated by allergic mothers are not the same as children born without such exposure.
Even within those categories each is child is genetically and epigenetically unique. Thus general advice needs to be tempered by knowledge of individual history.
In general, it is best not to exclude any foods from the mother’s diet, as breastfeeding is intended to create tolerance.
In general, it is also best to exclude from the diet of the pregnant woman and breastfeeding mother foods to which she –and/or the biological father of the child – is clearly reactive.
Those two general statements are complementary, not contradictory. They simply imply that public health messages need to be more nuanced, and families need more detailed support and assistance, than is currently true.
If such support is not possible, at least public health officials and hospital-based specialists could acknowledge such important differences and not make matters worse by arbitrary diktats about the one best age for introduction of solids, ignoring the experience of breastfeeding families and of those who work with their relatively normal children as allergy problems emerge in infancy. Hospital-based specialists – and following them, most community-based doctors – still fail to see the early end of the reactivity spectrum where these problems begin to manifest, and can be remedied more easily. Dietary intervention can lead to rapid improvement in young children – and others in the family, usually. Health policy should not be based on children sick enough to reach referral centres or meet strict criteria for existing allergy. Allergy is a wide spectrum, and the sooner it is identified and managed, the better chance there is of creating tolerance over time.
Where to from here?
WHO’s population-level advice is to breastfeed exclusively to six months, and introduce other suitable foods while continuing to breastfeed ‘into the second year and beyond’.
WHO has always urged the use of appropriate individual growth monitoring to guide individual care. But it is not enough for WHO and other health authorities to tell us what is appropriate for breastfed babies. WHO also needs to spell out clearly that:
- what is true for breastfed babies does not apply to artificially fed babies; both science and commonsense suggest that it is unlikely to, given the differences between the fluids and their delivery mechanisms.
- each company that creates artificial formulas needs to specify appropriate and safe complementary feeding suggestions for their products, as each formula is unique
- six months/26 weeks is not an absolute minimum or maximum for the introduction of other foods to breastfed babies
- widening the diet of artificially fed infants once body stores are exhausted is ‘nutritional insurance
- using toddler formulas is not nutritional insurance and can be nutritional risk
- population recommendations are just that – growth monitoring and parental care of each baby is essential to good individualised decision-making
- growth monitoring is about individual growth trajectories, weight for height, and proportionality, not simply gross body size and averages. Of course the breastfed baby’s growth should be plotted on the WHO growth charts, finalised in 2006, and based on breastfed children. Older charts have been based on US (almost all) bottle-fed children. The US CDC, the Centers for Disease Control and Prevention, has adopted the WHO charts for children up to the age of two, yet to date some countries have not. The WHO charts indicate substantial differences in normal child growth from those based on bottle-fed populations. It would greatly assist all families to know the normal growth curve of well-breastfed infants. Deviations could be uncovered sooner. The UK has not only adopted the WHO charts, but made available training materials in their use.2061 Other countries are following suit. However, it may not be possible for formula-fed infants to follow the growth trajectory of breastfed infants without risking nutrient imbalances: greater intake and weight gain may be inevitable for the child to obtain necessary micronutrients less bioavailable in formula. There is still a great deal unresearched about both infant formulas and breastmilk. Every formula change creates a whole new experiment.There are numerous salutary lessons to be drawn from the introduction of solids debacle, not least the power of industry and the media to shape and inform public opinion. With industry websites multiplying, more effective means of reaching parents with factual information about appropriate complementary foods are needed. Surely this should be the concern of national paediatric dietitian groups? And surely they need to critique what is reaching parents from industry-aligned sources.For the present the only sites I can strongly recommend are:First Steps Nutrition Trust (http://www.firststepsnutrition.org)Saadeh R. Complementary Feeding: family foods for breastfed children. (WHO Geneva 2000). Update the recommendation to 6 months, but very practical. Online at http://www.who.int/nutrition/publications/infantfeeding/WHO_NHD_00.1/en/Baby Led Weaning site, (www.babyledweaning.com/)My Child Won’t Eat! by Spanish paediatrician Carlos Gonzalez; you can read about him at http://www.theguardian.com/lifeandstyle/2012/may/28/carlos-gonzalez-doctor-parents=break-rules
Advice from reliable breastfeeding organisations such as LLLI (La Leche League International) – http://www.llli.org/ – and ABA (Australian Breastfeeding Association) –https://www.breastfeeding.asn.au/ to single output just two of many worldwide.
2024 Cone T. A History of American Pediatrics. (Little Brown and Co. 1979) p.257. Farex and rusks had both been wheat-based, though mixes including rice became more popular during 1970s – perhaps beginning the sequence of events that led to FPIES. (See p. 526 )
2025 Barness L. Reply to Ganelin letter. Pediatrics 1981; 67:165-6
2026 Vahlqvist B. The Evolution of Breastfeeding in Europe. J Trop Ped Envir Child Hlth 1975; 21:11.
2027 Gonzalez C, op.cit.
2028 Ross E. Love and Toil. Motherhood in Outcast London 1870-1918. (OUP 1993) p. 142
2029 Akre J (ed) Infant Feeding the Physiological Basis op cit., ch.
2031 Lanciers S, Mehta DI, Blecker U, Lebenthal E. The role of modified food starches in baby food. (PMID:9188246) Journal of the Louisiana State Medical Society 1997; 149(6):211-214
2032 The Feeding of Solids debate. Barness LA reply to Ganelin RS, Pediatrics 1981; 67 (1) :166; cited in all editions of Breastfeeding Matters (p.356, 1998 edition). Barness also reported that he had received many ‘bitter letters..stating that solid feedings at one month have untold advantages.’ Maybe they did for formula-fed children! They don’t for the breastfed.
2033 The report is available as pdf download or searchable text @ www.idfa.org.uk/inform IDFA is also the acronym for the International Dairy Foods Association, a global lobbying group.
2034 Who might have been some of the anonymity-requesting INFORM contributors thanked so profusely in the Report. Covert –paid?- assistance to industry makes it impossible to assess the impartiality of those contributing to public debate on this subject.
2035 Fewtrell M, Wilson DC, Booth I, Lucas A. Six months of exclusive breast feeding: how good is the evidence?(PMID:21233152) BMJ 2011, 342:c5955.. The answer to that question is: much better than the information, hypotheses, assumptions and interpretations found in this article!
2036 ESPGHAN Committee on Nutrition: Complementary Feeding: A Commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2008; 46: 99-110
2037 Appallingly, in perhaps the worst mistake of an otherwise generally useful document, the 2013 NHMRC Infant Feeding Guidelines for Healthworkers (op. cit) lent it credibility by describing it as ‘a systematic review.’
2038 Martyn C. Lactation wars Published 9 February 2011; BMJ 342 doi: 10.1136/bmj.d835
2042 Oski F. op.cit.
2043 Fomon (1974) pp 16-17 summarises trends in feeding vegetables over the century.
2044 Mennella JA Mother’s milk: a medium for early flavor experiences. (PMID:7748264) Journal of Human Lactation 1995, 11(1):39-45.
2045 Burnier D, Dubois L, Girard M Exclusive breastfeeding duration and later intake of vegetables in preschool children. (PMID:20978527 Eur J Clin Nutr 2011, 65(2):196-202.
2046 This is a typical example of unconscious bias: if breastfeeding is associated with a beneficial outcome, researchers often attribute this to socio-economic factors associated with breastfeeding; butfail to cross-link one known outcome of breastfeeding (vegetable eating) with yet another beneficial outcome, lower NCD rates.
2047 Shim JE, Kim J, Mathai RA. Associations of infant feeding practices and picky eating behaviours of preschool children. J Amer Diet Ass 2011; 111 (9): 1363-8.
2048 Hausner H, Nicklaus S, Issanchou S, M.lgaard C, et al. Breastfeeding facilitates acceptance of a novel dietary flavour compound. (PMID:19962799) Clinical Nutrition 2010, 29(1):141-148.
2049 Remember, a former industry scientist is on record as describing hydrolysate formulas as tasting ‘like mud,’and ‘horrible’, saying that..’I mean, you would never drink it. But you would probably have a hard time when the formula bottle was open to be in the same room with it.’ Transcript, FDA Food Advisory Committee meeting Nov 18, 2002. Op.cit.
2050 Northstone K, Emmett P, Nethersole F, The effect of age of introduction to lumpy solids on foods eaten and reported feeding difficulties at 6 and 15 months.(PMID:11301932) J Hum Nutr Diet 2001;14(1):43-54.
2051 Scott JA, Chih TY, Oddy WH. Food variety at 2 years of age is related to duration of breastfeeding. (PMID:23201765) Free full text article Nutrients 2012, 4(10):1464-1474
2052 Kramer and Kakuma (2002, revised 2009; revised 2011) Optimal duration of exclusive breastfeeding.(PMID:22895934) Cochrane Database of Systematic Reviews (Online) 2012, 8:CD003517. DOI:10.1002/14651858.CD003517.pub2
2053 This ESPGHAN expert opinion has been well critiqued by Cattaneo A, Williams C, Pall.s-Alonso CR,Hern.ndez-Aguilar MT et al. ESPGHAN’s 2008 recommendation for early introduction of complementary foods: how good is the evidence? Mat Child Nutr (2011), 7: 335-343.
2054 ESPGHAN once expressed concern (J Pediatr Gastroent Nutr 2008; 46:99–110) about macrobiotic diets and vegans on the basis of a Dutch study showing poorer growth in infants. This was of 53 infants who had water-based, no-fat vegetable porridges given from around 4-5 months, displacing breastmilk fat and protein. Interestingly, low breastmilk output at 6 months (mean of 363ml) correlated with wasting in these children; BUT intakes at 6 months of an average of 824 mls did not. See Dagnelie PC, van Staveren WA. Macrobiotic nutrition and child health: results of a population-based, mixed-longitudinal cohort study in The Netherlands. Am J Clin Nutr 1994; 59(5 Suppl):1187S–1196S
2055 EFSA Journal 2009; 1423: 11-38
2056 Hornell A, Lagstr.m H, Lande B, Thorsdottir I. Breastfeeding, introduction of other foods and effects on health: a systematic literature review for the 5th Nordic Nutrition Recommendations. (PMCID:PMC3625706) Food Nutr Res 2013, 57:313-323.
2057 SACN Infant Feeding Survey 2005 op. cit.
2058 AAP Section on Breastfeeding. Breastfeeding and the Use of Human Milk. Pediatrics 2012; 129 (3): e827 -e841.(doi: 10.1542/peds.2011-3552. Online: http://pediatrics.aappublications.org/content/129/3/e827.full
2059 EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA): Scientific Opinion on the appropriate age for introduction of complementary feeding of infants. EFSA Journal (2009) 7(12):1423
2060 Lucas A. Infant Nutrition. Op. cit p. 50.
2061 These can be downloaded from the Dept of Health website: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/@sta/@perf/documents/digitalasset/dh_127422.pdf