3.7 Looking Forward: The Importance of Exclusive Breastfeeding

Breastfeeding is widely practiced throughout the developing world and is actually improving in spite of demographic trends, such as urbanization, which exert a downward pressure.⁴⁰ Nonetheless, there is a need to increase the duration of exclusive breastfeeding because this breastfeeding behaviour is most associated with infant health and survival. Three published studies have demonstrated the effect of breastfeeding promotion on the duration of exclusive breastfeeding.^45-47 Interpersonal counselling was the key intervention. Breastfeeding promotion is one of the most cost-effective interventions to promote child health and is comparable to immunizations.⁴⁸

Increasing the duration of breastfeeding does not necessarily lead to increases in the duration of exclusive breastfeeding. In Bolivia and Colombia, the duration of partial breastfeeding has increased at the same time the duration of exclusive breastfeeding has decreased. However, in countries where a concerted effort has been made to increase exclusive breastfeeding, shifts in population-level behaviours have been noted. In the Dominican Republic and Peru, the proportion of infants under four months of age who were exclusively breastfed doubled between 1991 and 1996 and between 1986 and 1996, respectively.²⁹

The timing of interventions to promote the desired breastfeeding and complementary feeding behaviour is critical because it is likely to affect a mother’s decision-making, her motivation to overcome problems should they arise, and her persistence in maintaining a recommended behaviour despite negative influences. Therefore, interventions need to be delivered as close as possible to the time of the desired behaviour. Exclusive breastfeeding declines precipitously in the first month of life. Evidence shows that in the short term women can be encouraged to return to exclusive breastfeeding with counselling.⁴⁶ However, once women cease exclusive breastfeeding they usually do not resume. Therefore, reaching women during the prenatal period, soon after delivery, and within the first month postpartum is critical to increasing the duration of exclusive breastfeeding.

The challenge from a public health perspective is to translate the vast scientific literature on breastfeeding and complementary feeding recommendations to effective interventions that are understood and accepted by the population at large. To some extent lessons learned from campaigns to promote breast-feeding can provide guidance. However, as important as breastfeeding is to infant health and survival, it is also necessary to look beyond breastfeeding and to integrate both breastfeeding and complementary feeding in campaigns to promote optimal nutrition of both the infant and young child. As noted in a recent review, providing safe and adequate amounts of foods appropriate for infants and young children is not simple.²¹ Complementary foods must be adequately dense in energy and micronutrients to meet the requirements of this age group. They must also be prepared, stored, and fed in hygienic conditions to reduce the risk of diarrhoea. Lastly, many feeding behaviours that affect infant and child nutritional status need further study. Qualitative and quantitative research is necessary, along with cost-effectiveness analysis. However, research is not sufficient to guarantee the success of public health interventions. The international community must work together to ensure that the same rigor applied to such research is applied to broad-scale interventions, to bring the benefits of nutrition research to those who need it most.